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SEKN Final Report February 2008
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SEKN Final Report February 2008
Acknowledgements
This report has been written by members of the regional hubs of the Social Exclusion
Knowledge Network (SEKN). The SEKN is one of nine global Knowledge Networks
established by the WHO (World Health Organisation) Commission on the Social
Determinants of Health (CSDH). As with all such reports it has benefited greatly from the
input of many people. We are particularly grateful for the collective inputs, contribution and
expertise generously offered by other Knowledge Network Members at our meetings and
through email exchanges and from authors of the SEKN Background Papers. A full list of
these contributors is provided below but we would like to express our particular thanks to
Etheline Enoch (UK hub) who made an important contribution to developing the framework
for this report, Jackie Cox (UK hub) and Nico Jacobs (South Africa hub) who provided
invaluable assistance organising network events. Thanks are also due to Sarah Simpson
and Anand Kurup from the World Health Organisation (WHO) Geneva, and Sebastian Taylor
from University College London who, as members of the Commission secretariat, have given
unstinting support and invaluable guidance. The external referees also deserve a special
mention, who despite the challenges of an incomplete draft of the report provided insightful
comments and suggestions for improvements for which we are grateful. We regret that we
have not been able to respond fully to these due to time constraints.
Finally, we wish to thank our institutions, Lancaster University, United Kingdom; Human
Sciences Research Council, South Africa; Fiocruz, Brazil; the National University of
Colombia and Javeriana University, Colombia, and ICDDR, B, Bangladesh for giving a home
to the organisational hubs of the Knowledge Network.
Disclaimer
This work was made possible through funding provided by the World Health Organisation
(WHO). The views presented in this report are those of the authors and do not necessarily
represent the decisions, policy or views of WHO or of Commission on Social Determinants of
Health (CSDH) Commissioners.
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CONTENTS
EXECUTIVE SUMMARY 7
Part I: INTRODUCTION 23
Chapter 1: The Social Exclusion Knowledge Network and its work 24
REFERENCES 196
APPENDICES
Appendix 1: The policy appraisal analytical framework 201
Appendix 2: List of abbreviations used in the report 205
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Tables
1 SEKN Background Papers
2 The EU Laeken Indicators of inclusion/exclusion
3 Pochmann’s Social Exclusion Index – Brazil
4 Examples of Theory-driven Approaches to Measuring Social Exclusion - UK
5 Impact and lessons from Universal Health Care Policies
6 Benefits and Limitations of Conditional Cash Transfer Programmes
Figures
1 SEKN Structure and Global Reach
2 Social Exclusion: Discursive Diversity
3 The SEKN Model of Social Exclusion
4 Displacement and Exclusionary Processes in Colombia
5 A Global View of HIV Infection
6 Exclusionary Processes Impacting on Indigenous People in Latin America
7 Map of Human Development Indices 2004
8 A Typology of Actors and Actions to Address Exclusionary Processes
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1
Available on the WHO CSDH website or contact j.cox@ Lancaster.ac.uk for more information
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Social exclusion has most policy salience in Western Europe where it was first developed.
Although it has spread well beyond the EU it does not have equal policy/action salience in
other regions, nor does it have the same meanings across any particular global region. As a
description of an extreme state of disadvantage, the concept is particularly problematic in
regions and countries where large proportions of the population are living in poverty. In
these contexts, alternative discourses have greater relevance for policy and action.
However, the relational approach to social exclusion adopted by the SEKN helps to broaden
the global relevance of the concept and has particular advantages including:
o Providing a wider lens to understand the causes and consequences of unequal power
relationships.
o Making explicit the links between exclusion and a ‘rights’ approach to the social
determinants of health.
o Directing analytical attention to interactions between relationships and outcomes at
different levels e.g. community, nation state and global regions.
o Highlighting both active and passive exclusionary processes.
o Recognising that exclusionary processes will impact in different ways to differing degrees
on different groups and/or societies at different times.
o Recognising an inclusion/exclusion continuum and allowing for the possibility of
inequitable inclusion and extreme exclusion as well as the possibility of differential
inclusion/exclusion along different dimensions, hence having global relevance.
o Avoiding the stigma of labelling particular groups as ‘excluded’.
o Acknowledging the potential for groups and/or nations to actively resist exclusionary
processes and their ensuing negative consequences.
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SEKN Final Report February 2008
outcomes, being unable to prioritise or measure the interaction between factors and
emphasising economic and social dimensions whilst giving less attention to political and
cultural dimensions. Measures of the relationship between social exclusion and health
outcomes are also highly problematic. Measures of social exclusion can themselves be
‘exclusionary’ as people most severely affected by exclusionary processes –the stateless,
the homeless, marginalised indigenous people and people living in institutions – are often
the least likely to be counted. This limitation of quantitative measures is compounded by
the neglect of the voices of people most severely affected by exclusionary processes.
In an attempt to move beyond the limitations of formal quantitative indicators the SEKN has
used case-studies to provide a window on the nature and scale of exclusionary processes
and their impacts. These thematic case-studies focus on economic inequalities and poverty,
displacement, HIV and AIDS, and cultural discrimination. The SEKN believes that the nature
and impact of exclusionary processes can only be adequately ‘represented’ through both
quantitative and qualitative data – through both indicators and stories. This is the only way
to maximise effective policy and action to address exclusionary processes.
More recently the advantages of comprehensive systems of social protection and universal
public provision of services such as healthcare, education, water, sanitation, etc are again
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SEKN Final Report February 2008
being recognised and their introduction in countries such as Venezuela, South Africa and
Brazil has been associated with major improvements in access and use of services,
reductions in poverty levels and there is evidence of positive health and educational
outcomes and greater social cohesion and solidarity. Public provision of social protection
and essential services also has the potential to generate significant multiplier effects in local.
Funding these services is clearly an important challenge. There is a need for multi-lateral
agencies and donors to rise to this challenge and develop ways for universal systems of
social protection and essential services free at point of use to be funded in low- and middle-
income countries, including global tax systems.
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Conditional transfer programmes are a particular type of targeted policy that is dominating
the global scene. A growing body of research suggests that these programmes can have
significant positive impacts including poverty reduction, improved living standards and
improved health and educational outcomes. However, potential benefits notwithstanding,
not only do these policies have all the limitations of unconditional targeted action they are
open to other criticisms. Some programmes, for example, fail to provide the services people
require to meet the conditions, and/or pay little attention if any to the often poor quality of
services. When conditionality refers to labour market participation, the quality and
sustainability of employment is often neglected or ignored. Furthermore, evidence on the
‘value added’ nature of ‘conditionality’ per se is inconclusive; whilst other evidence suggests
if conditions ‘fit’ with household priorities – to protect child health for example - ‘conditionality’
is not needed. Perhaps most importantly, is a large body of evidence accumulated over
many years that conditional and even punitive forms of transfers are counter-productive for
social cohesion, wellbeing and productivity.
Insurance based schemes targeting the poor are being proposed by some commentators as
an effective approach to providing access for people on a low income to essential services
such as healthcare and/or protecting against the risk of natural hazards and ill-health. Some
low- and middle-income countries, for example, are introducing state-subsidized healthcare
insurance schemes, often in partnership with private sector organizations. Evidence
suggests that these schemes are associated with an increase in public resources directed at
poor people which leads to an increase in health-service users. However, critics point to
problems with equality of access to effective services, to the poor quality of services, neglect
of preventive services and to poorer health outcomes associated with these systems. These
systems have similar problems to other targeted policies/actions: complex and restrictive
eligibility procedures, high risk of fraud and corruption and limited capacity to meet demand.
Another model of social insurance, more common in Asia, is schemes run by NGOs which
protect people against catastrophic health events and/or environmental hazards such as
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SEKN Final Report February 2008
floods and drought. Whilst large scale examples of these schemes in India have been
reported to be very successful, the example included in the SEKN appraisals in Bangladesh
illustrates the limits of such schemes in very poor communities where the resource base is
insufficient to fund adequate cover.
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Community involvement can be the key to successful policy and/or action to reverse
exclusionary processes but it cannot solve large-scale structural problems. Community
involvement can only be effective when embedded in effective state action to provide decent
living standards for all and universal access to essential services. In this context, community
involvement can ensure that the full range of relevant knowledge – lay and professional,
scientific and experiential – informs policy and action and hence increases the likelihood of
these policies and actions being appropriate, acceptable and effective. However, in many
countries the knowledge of lay people, particularly indigenous peoples, is devalued and
ignored. Without support, community activists can be damaged by their experiences –
blamed by their communities for failing to deliver real change and held accountable by
professionals for the communities they represent. Professional workers will often resist the
challenge to their power-base, which is inherent in effective community involvement.
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Multi-lateral agencies and other international donors can act as role-models and promote
good practice in their own relationships with non-governmental organisations and
communities. In their funding policies they can provide incentives for governments to work
effectively with communities and NGOs, resource capacity building for non-governmental
organisations, community action and community involvement, and simplify regulations for
grants so that smaller community and voluntary groups can access funds and hence develop
capacity. They also have a powerful advocacy role, promoting legal protections for non-
governmental organisations and community action within nation-states.
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SEKN Final Report February 2008
conditions of paid labour is reasonably well developed in high-income countries but has
been under attack in recent years, and even in the most regulated economies there are
segments of the labour force where conditions are very poor. In many countries of the world
such legislation is non-existent. Voluntary initiatives to promote compliance standards and
to encourage greater social responsibility in the private section can lead to improved labour
conditions and may have wider impacts on exclusionary processes, but the reach and
impact of these initiatives are insignificant set against the powerful exclusionary processes
driven by current global trade relationships. Wider social movements including action by
large international NGOs are increasing the pressure on the private sector to comply with
higher labour standards and demonstrate greater social responsibly in terms, for example, of
investing in low communities and protecting the environment. However, as the reports of the
Globalisation and Employment Conditions Knowledge Networks powerfully demonstrate,
these initiatives are having only a marginal impact on the scale of exclusionary processes
currently driving social and health inequalities around the globe.
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1. Recognise the underlying relationship between social inclusion and human rights:
action to promote and protect human rights will reverse exclusionary processes
and promote social cohesion.
2. Be clear about the added value the concept will bring to understanding the
problems to be targeted and shaping the actions to be taken.
3. Promote public debate about the potential benefits and dis-benefits of the
concept as a framework for policy and action.
4. Only use the term 'social exclusion' when more precise and informative
descriptors of the phenomena to be targeted, such as food insecurity or racism,
are not available.
5. Focus on the multi-factorial relational processes driving differential inclusion and
conditions of extreme exclusion, rather than solely on ameliorating the conditions
experienced by groups labelled as ‘social excluded’.
6. Attend to all the dimensions of exclusionary processes - social, political, cultural
and economic – and the interactions between them when developing,
implementing and evaluating policy and action.
7. Consider the value of using the SEKN conceptual model as a tool for developing
more comprehensive policy and action to address social exclusion and as a
framework for evaluation.
Recommendation theme 2: The primacy of universal rights and full and equal
inclusion
The primary aims of policies/action aimed at reversing exclusionary processes should be to:
• Promoting full and equal inclusion to social systems
• Provide universal access to living standards which are socially acceptable to
all members of a society, including access to the same level and quality of
health and educational services, safe water, sanitation and ‘decent work’, as
defined by ILO.
• Respect and promote cultural diversity.
• Address unequal inclusion as well as situations of extreme exclusion.
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The conditions are located at the level of communities and/or groups rather
than individuals or households.
Conditions are prioritized by these communities and/or groups rather than
being centrally determined.
Policies and actions are administered and monitored locally through
participative mechanisms.
The services and/or resources necessary for conditions to be met must be
available and readily accessible.
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need for initiatives which aim to support greater co-ordination across sectors and actors.
These initiatives work more effectively when the following conditions are in place: In general
initiatives aimed at improving the co-ordination and/or integration of policy work more
effectively if the following conditions are in place:
• Monitoring systems combining objective indicators with experiential/subjective
understandings and capturing dynamic processes, not just describing changed states.
• Explicit recognition that action to address exclusionary processes requires formal
mechanisms to manage inevitable political processes. International agencies can help to
establish social exclusion and poverty as bi-partisan issues at a national level.
• Strong and senior political commitment and leadership.
• Institutions established to take the initiative forward independent of the state, with
credibility as knowledge brokers/translators, the power to make decisions, to hold others
to account for action e.g. a Standing National Commission or an Independent Board.
• Institutional actors with credibility and stature to act as champions for policies/actions.
• A process to ensure sustainability of the initiatives in the longer term by integrating
changes into mainstream policy-making processes and service delivery systems.
• Resources and time for capacity-building e.g. technical skills and competencies for
problem definition, knowledge generation, translation, implementation and monitoring.
The initiatives appraised also point to the value of ensuring adequate opportunities for
sharing of learning across national and sub-national contexts.
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SEKN Final Report February 2008
legislation, and the benefits of corporate social responsibility should be more carefully
analysed and publicised.
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PART I INTRODUCTION
This first part of this report consists of a single chapter which describes the relationship
between the SEKN and the WHO Commission on the Social Determinants of Health; how
the SEKN has organised itself; and who has been involved in the work. It then moves on to
explain how knowledge on social exclusion has been identified and appraised, commenting
on the limitations of the work, before describing how the rest of the report is structured.
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SEKN Final Report February 2008
This is the final report of the SEKN. The SEKN consists of four regional hubs, individual
representatives from other regions and representatives from the Commission secretariat.
The global reach of the SEKN is shown in Figure 1 below.
Europe:Lancaster, UK
Jennie Popay South East Asia: ICCD,RB &
BRAC: Co-ordinator
- Heidi Johnston
South America: Colombia.
National & Javeriana
Universities
Co-ordinator: Mario Hernandez
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SEKN Final Report February 2008
The four regional hubs are: Sub-Saharan Africa (based at the Human Sciences Research
Council in Pretoria, South Africa); South East Asia (based at ICDDR, B in Dhaka,
Bangladesh); Europe (based at the Institute for Health Research, Lancaster University,
England) and Latin America (based at Fiocruz, Rio de Janeiro, Brazil and the National
University of Colombia and Javeriana University, Bogota, Colombia). The Europe Hub also
provides a co-ordinating function. In addition to these regional hubs the network has had
representatives from the WHO Western Pacific and Eastern Mediterranean Regions as well
as representatives from other knowledge networks, from the Commission’s civil society
facilitators and from the WHO commission secretariat in Geneva and London. The important
contribution made by these members has been invaluable, but inevitably the work of the
network - and particularly the policies and actions appraised - has been largely confined to
the global regions where SEKN hubs were based. Even within these regions the limitations
of resources and time have restricted the number of countries included in the work. Details
of the full membership of the SEKN and other individuals who have contributed to our work
can be found on page 4 of this report.
The SEKN has been working to a challenging timetable. The hubs in Sub-Saharan Africa
(SSA), South East Asia (SEA) and Europe formally began work in the last quarter of 2006
while the Latin American hubs were established in January 2007, giving us around 9 months
to complete our programme. Our devolved structure has enhanced our ability to access
global knowledge and established a firm foundation for future collaborative action at a global
level to address the health consequences of social exclusion. However, participatory
processes are time-consuming and in the short term our inclusive structures have
exacerbated the time constraints facing us. Hence the SEKN work programme, particularly
the number and type of policies/actions appraised and the depth of the appraisals, have
been determined by a combination of pragmatism and the scope of the work agreed with
WHO.
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SEKN Final Report February 2008
The policy and/or action appraisals were of two main types: firstly, appraisals of particular
policies/actions without detailed attention to the country context in which they are being
implemented; and secondly, more extensive country case-studies. The latter aimed to:
• assess the current impact of exclusionary social processes on key social
determinants of health in particular country contexts;
• provide summary descriptions of a range of policies, programmes and/or institutional
arrangements aimed at addressing exclusionary processes; and
• focus in more detail on a small number of policies/actions identified.
Globally, few policies and actions are explicitly described as addressing social exclusion, so
we had to use a conceptual framework (described in the next chapter) to decide on
relevance. As a consequence of time constraints, the policies and actions selected are
neither exhaustive of all potentially relevant actions nor are they necessarily the most
obvious or largest initiatives aiming to address social exclusion. Additionally and importantly,
selection of a particular policy/action is not intended to signal an endorsement by the SEKN
or to suggest that they represent examples of good practice in addressing social exclusion.
On the contrary, our aim has been to appraise policies/actions in order to form a judgement
about the relative merit of different approaches.
In this context the selection criteria included: global reach; diversity; availability of relevant
documentation and potential for comparative analysis within and across global regions.
• Global reach: we aimed to identify and appraise policies from as many countries and
global regions as possible. However, we could not include action/policies from WHO
EMRO and have included only one policy appraisal from Australia in the WHO WPRO.
• Diversity: we aimed to collate knowledge on a range of policies/actions in terms of:
o The ‘lead’ agents involved in the policy/action
o The substantive focus of the policy/action
o The target of the policy/action
o The level at which policy/action was implemented.
• Availability of relevant documentation: within the time available it was necessary to
confine literature reviews largely to the English language literature, but some literature in
Spanish, Portuguese and French was also included. The appraisals were also confined
to policies/actions for which descriptive and evaluative information was readily available.
The country case studies are primarily but not exclusively focused on countries with
regional hubs.
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SEKN Final Report February 2008
• Potential for comparative analysis within and across global regions: where possible
examples of policy/action models that were common across countries and global regions
were included for review. These included examples of conditional cash transfer
schemes, approaches to integrating service development and delivery and methods for
extending rights to healthcare.
With these criteria in mind, SEKN hubs used personal and professional contacts at
international, national and/or local level and non-governmental organisation (NGO)
facilitators working with the WHO CSDH to identify potentially relevant policies and actions.
Inevitably, we identified a far larger number of potentially relevant policies/actions than we
had time to appraise. We are therefore establishing a database of those not yet appraised
and intend to seek funds to develop this database and undertake further appraisals.
The policies and actions selected for appraisal involve multi-lateral agencies, national and
local government, non-governmental organisations and community groups., and focus on
topics such as poverty reduction/eradication, the provision of new services, initiatives to
improve access to existing services and/or to improving the co-ordination of policies. More
details of the policies and actions appraised are included in the SEKN Background Papers
listed in Table 1 below. Further details on how to obtain copies of these papers are available
from the UK hub: j.popay@lancaster.ac.uk
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Notwithstanding the diversity, the appraisals were all undertaken within a broad analytical
framework developed by the SEKN. Country case studies included one or more of the three
elements described below whilst specific policy/action appraisals included only the third.
iii. In-depth appraisal of one or more of the policies/actions identified. This work
included attempts to obtain information on the experiences of people implementing the
policies/actions and the groups targeted by the policy/action, including limited focus group
work with beneficiaries of programs for poor people. .
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SEKN Final Report February 2008
Detailed sets of questions relating to each stage of a case study and/or policy/action
appraisal were also developed. These were used both to inform the analysis of secondary
data and the collection and analysis of primary data from key informant interviews where
these were conducted. The analytical framework and related questions are included in
Appendix 1.
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SEKN Final Report February 2008
at the global, regional and national levels to develop strategic approaches to the
development and/or co-ordination of policies/actions targeting social exclusion (Chapter 7);
and the role of corporate social responsibility in the private ‘for profit’ sector (Chapter 8).
Part IV presents a summary of the key messages from the work of the SEKN in Chapter 9,
followed in Chapter 10 by the recommendations of the SEKN to the WHO Commission on
the Social Determinants of Health.
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SEKN Final Report February 2008
Part II of this report focuses on issues related to the definition and measurement of social
exclusion. Chapter 2 describes the general approach to the concept of social exclusion
adopted by the SEKN and presents the conceptual model we have developed. The global
salience of the concept of social exclusion is considered, as is the relationship between
social exclusion, population health and health inequalities. Chapter 3 presents a series of
thematic case studies to explore the nature, scale and impact of exclusionary processes,
before describing some of the formal approaches to measurement which are available or
being developed.
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SEKN Final Report February 2008
An important distinction must be made between the use of the phrase ‘social exclusion’ to
describe a ‘state’ as opposed to its use to describe multi-dimensional processes. In a policy
context, social exclusion is most commonly used to describe a ‘state’ in which people or
groups are assumed to be ‘excluded’ from social systems and relationships. In most
definitions this state is seen to be associated with extreme poverty and disadvantage. As
one author notes, the term is now so widespread that it has become ‘a cliché used to cover
almost any kind of social ill’ (Bessis, 1995). Many definitions include ‘indiscriminate’ lists
describing groups excluded or at risk of exclusion, what they are excluded from, the resultant
problems and the ‘actors’ responsible for excluding groups. Beginning in France in the
1970s, a discourse of social exclusion (and inclusion) as a ‘state’ and policies and actions
informed by this concept have spread from the North to the South, mainly through the efforts
of United Nations agencies such as the International Labour Organisation (ILO) and the work
of individual nation states such as the aid programmes of the Department for International
Development (DFID) in the United Kingdom.
However, as Figure 2 illustrates, the work of the SEKN has highlighted important nuances in
the nature of social exclusion discourses around the world, and importantly in some regions
alternative discourses addressing the same or similar social realities appear to have greater
policy/action salience. In Sub-Saharan Africa, for example, the dominant discourse
continues to be focused on poverty, marginalisation, vulnerability and sustainable
development. Even within global regions, social exclusion is not a uniform concept. In Latin
America, the concept is embedded in a ‘social management of risk’ discourse promoted by
the World Bank. This discourse is prominent in countries where these agencies are
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SEKN Final Report February 2008
influential, for example in Columbia, but not in other countries, such as Brazil, where the
influence of French academics is apparent and the progressive branch of the Catholic
church is more influential. However, PAHO concepts of “Social Exclusion in Health" and
"Social Protection in Health“ also have wide salience across Latin America as does
CEPAL/ECLAC’s (Economic Commission for Latin America and the Caribbean) concept of
“Social Cohesion” promoting strategies for social inclusion and a collective sense of
belonging in societies. In south-east Asia, as in other global regions, the term social
exclusion is being introduced by international development agencies but the discourse
retains a focus on multiple dimensions of poverty and on concepts of capability and resource
enhancement that resonate with previous discourse and practice in the region.
In some regions and countries, notably Europe and Australia, the concept of social
exclusion is being overtaken by its mirror, social inclusion, whilst work by the SEKN has also
highlighted overlaps between the concept of social exclusion and related concepts such as
social cohesion, social capital, social justice and human rights and constituent elements of
these concepts such as empowerment, emancipation, disaffiliation and marginalisation.
These overlaps and the implications for policy and action are discussed in more detail in the
SEKN Background Papers. Suffice it to say at this point, that in considering the relevance of
social exclusion as a conceptual framework for policy and action to address the social
determinants of health, the WHO Commission must acknowledge and take account of this
existing diversity in the meanings attaching to the term.
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SEKN Final Report February 2008
Social E
Global: xclusion:diversity
geographic Discurs ive Diversity
within regions
European Union: the concept of social exclusion developed in
France closely linked to labour market participation and welfare South East Asia:
provision. It was quickly adopted as a focus of EU policies with a concept being
shift to social inclusion over time. introduced by
development partners
e.g. DFID, the UNDP
and the Asian
Development Bank.
However, defined in
terms of multiple
dimensions of poverty
capability & resource
enhancement
resonating strongly
with longstanding
development discours
and practices in the
South America: SE is
region.
embedded in a ‘social
management of risk’ discourse
promoted by the World Bank
and prominent in countries
where these agencies are
influential e.g. Columbia but
not in other countries e.g.
Brazil where the influence of
French academics is apparent
and progressive branches of Sub-Saharan Africa: The discourse of SE
the Catholic church are more is being introduced primarily by
intense. PAHO works with the international aid agencies and there is an
concepts of “Social Exclusion emerging body of academic work on the
in Health" and "Social salience of SE for Sub-Saharan Africa.
Protection in Health“ which However, the alternative discourses of
have wide salience across poverty, vulnerability, basic need and
South America as does sustainable development continue to
ECLAC’s concept of “Social have wider salience.
Cohesion” promoting
strategies for social inclusion
and a collective sense of
belonging in societies.
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SEKN Final Report February 2008
The essence of a relational perspective on social exclusion is vividly captured in the Nguni
proverb quoted at the beginning of this report. As the proverb suggests, human beings
become social through the relational webs they create and sustain or, as another translation
of the proverb suggests: “All things depend on all other things for their existence”. Relational
interdependence is the driving force in all social systems: the weaker these relationships, the
weaker the force for progressive and sustainable change and development. Recognising
social systems as interdependent reveals the wider costs of exclusionary processes which
restrict the ability of groups, whole nations and global regions from participating fully in these
social systems. A focus on relational interdependence in the working of any social system
also makes explicit the individual and collective self interest inherent in pursuing
policies/actions to promote positive inclusion: we all gain by creating more inclusive cohesive
social systems even if the redistribution of economic resources and power is a pre-requisite
for these gains. The definition of social exclusion developed the SEKN is presented below
highlighting key elements of this relational perspective.
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SEKN Final Report February 2008
Building on the work of Sarah Escorel (1999) the SEKN went on to develop a conceptual
model of social exclusion to inform our work. This is shown diagrammatically in Figure 3
below and highlights four dimensions of the power relationships that constitute the
continuum from inclusion to exclusion – economic, political, social and cultural. We
recognise that these relational dimensions are analytical constructs and that in reality social,
political, economic and cultural relationships are interconnected and overlapping. Here they
are utilised as heuristic devices to aid understanding of exclusionary processes, to illuminate
pathways between these processes, population health and health inequalities and to provide
a framework for appraising policies and actions seeking to intervene in these processes.
The key characteristics of each dimension are described below:
I. The social dimension is constituted by proximal relationships of support and solidarity
(e.g. friendship, kinship, family, clan, neighbourhood, community, guanxi 2, social
movements) that generate a sense of belonging within social systems. Along this
dimension social bonds are strengthened or weakened;
II. The political dimension is constituted by power dynamics in relationships which
generate unequal patterns of both formal rights embedded in legislation,
constitutions, policies and practices and the conditions in which rights are exercised -
including access to safe water, sanitation, shelter, transport, power and services
such as health care, education and social protection. Along this dimension, there is
an unequal distribution of opportunities to participate in public life, to express desires
and interests, to have interests taken into account and to have access to services.
III. The cultural dimension is constituted by the extent to which diverse values, norms
and ways of living are accepted and respected. At one extreme along this dimension
diversity is accepted in all its richness and at the other there are extreme situations of
stigma and discrimination.
IV. The economic dimension is constituted by access to and distribution of material
resources necessary to sustain life (e.g. income, employment, housing, land, working
conditions, livelihoods, etc).
2
Guanxi is a central concept in Chinese society describing, in part, a personal connection between two people in which one is
able to prevail upon another to perform a favour or service, or be prevailed upon. (Source: Wikipedia, last updated 31.8.07)
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SEKN Final Report February 2008
Political
Health inequalities
Economic
Social
Cultural
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SEKN Final Report February 2008
In the model, exclusionary processes are located within social systems (e.g. the family,
households, nation states, global regions, etc) shown in the central square of the diagram.
For simplicity’s sake, the model assumes that these processes and their impact on health
inequalities operate in the context of pre-determined biological determinants (shown to the
left of the diagram). This suggests that biological determinants are separate and immutable
but there is a growing body of research revealing the complex interactions between biology
and society with powerful influences on health. Within social systems interactions between
the four relational dimensions of power – social, political, economic and cultural - generate
hierarchical systems of social stratification along lines of gender, ethnicity, class, caste,
ability and age. In turn, moving to the right of the diagram, these stratification systems, and
the unequal access to power and resources embedded in them, lead to differential exposure
to health-damaging circumstances whilst at the same time reducing people’s capacity
(biological, social, psychological and economic) to protect themselves from such
circumstances, and restricts their access to health and other services essential to health
protection and promotion. These processes create health inequalities which, as the arrows
suggest, feed back to further increase inequities in exposures and protective capacities and
amplify systems of social stratification.
In the SEKN model the pathways linking the impact of exclusionary processes to health
inequalities are both constitutive and instrumental. In terms of the former, having the right
and freedom to participate in economic, social, political and cultural relationships has
intrinsic value, and the experience of restricted participation can be expected to have
negative impacts on health and wellbeing. Instrumentally, restricted participation in these
relationships results in other deprivations: for example, being excluded from the labour
market or included on disadvantaged terms will lead to low income, which can in turn lead to
poor nutrition, housing problems etc., which contribute to ill health.
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generate differential exclusion and inclusion in social systems (e.g. caste systems,
gender, ethnicity, stigmatising illness, etc.,)
Finally, static definitions that view social exclusion as a ‘state’ produced by the poverty
experienced by minority groups in a particular society are not readily applicable to countries
or global regions in which the majority of populations are living in poverty, excluded from
formal labour markets, and have little if any entitlement to social protection in cash or kind. A
relational perspective, in contrast, allows the concept to be translated from its individualistic
roots in Western Europe into a global frame, and enables an analysis of the processes that
exclude whole nations and continents from full participation in the global community, from a
just share in the benefits accruing from social and economic development and, perhaps
more importantly, from having a voice in the nature and direction of such development.
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3.1 Introduction
There is disease based exclusion; class based exclusion; the exclusion drawn out of
the behaviour of health workers and the issue of marginalised and displaced people
and refugees. Quite often there is a pattern of social exclusion of rural and informal
settlement areas, and there is social exclusion on the basis of religion. Social
exclusion is very broad based in terms of how it manifests. There are certain
pathways ..., some of those are in policy-making, some of those are in budget
allocation, some of those are in the attitude and behaviour of health workers, some of
it is in the way health messages are targeted and accessible to people, others are
lack of understanding of social and cultural factors in the implementation of plans.
(Comment by a respondent interviewed for the South African case study, SEKN Background Paper 3)
Developing and targeting policy and action to address social exclusion and monitoring
implementation and impact requires an understanding of the nature and scale of the
phenomenon. However, gaining this understanding is a complex and problematic
endeavour. Although the number and sophistication of indicators of social exclusion is
increasing, there is no consensus on how it should be measured. Indeed, the discursive
diversity discussed in the previous section means that there can be no single set of
indicators of social exclusion which would have equal salience in different global regions and
nation states. Additionally, most of the available indicators provide descriptions of ‘states’ of
exclusion, neglecting (with notable exceptions) the relational nature of these ‘states’ and the
exclusionary processes generating them. They also neglect the voices of those most
severely affected.
There is ample evidence to suggest that the perspectives of people experiencing poverty
and disadvantage are not the same as professionals, policy makers and politicians with the
power to act. These diverging views were brought sharply into focus in a recent global
initiative by editors of scientific journals to disseminate knowledge on the nature of poverty
and action to address it. One journal asked a wide range of commentators worldwide—
including eminent global health advocates Jeffrey Sachs and Paul Farmer, health reporters,
activists, health researchers, and people living in poverty - which interventions, in addition to
alleviating hunger, they thought would best transform the lives of the world's poorest people.
The international development experts highlighted a range of political, social and economic
interventions with a particular focus on low-cost bio-medical and/or healthcare related
interventions including insecticide-treated bed nets, artemisinin-based combination therapy
for malaria, trained community health workers, promoting breast-feeding, and vaccinating all
children. In contrast, members of poor rural communities in Ayacucho, Peru talked about the
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wider social determinants of health including housing, food, family, and social interactions
(Yamey, 2007).
In an attempt to move beyond the limitations of formal quantitative indicators, in the first part
of this section we present an empirical picture of the nature and scale of exclusionary
processes and their impacts through four thematic case studies focusing on economic
inequalities and poverty, displacement, HIV and AIDS, and cultural discrimination. Case
study evidence was obtained from various sources, including academic literature,
international agency reports, journalistic accounts, the SEKN Background Papers and direct
accounts of exclusion disseminated through civil society organisations (CSOs). In the
second part of this section we consider some of the available indicators relevant to the
measurement of social exclusion, drawing particular attention to their limitations from the
perspective of the SEKN conceptual framework.
The concept of social exclusion in national and international policies has been criticised for
being ‘a broad screen, a curtain, which [hides] problems of desperate destitution’ (Gore &
Figueiredo,1997:44): irrelevant to regions and countries where a majority of people are
experiencing severe poverty. As a commentator in the South African SEKN research noted:
...about 25 million people in our country are really suffering from one kind of poverty
or another. That is not a small proportion of people excluded from the normal life of
the society. In fact it’s a normal life ….
However, as Sen argues (2000:6) ‘the real importance of the idea of social exclusion lies in
emphasizing the role of relational features in the deprivation of capability’ and thus
highlighting the causal relationship between poverty and wider inequalities in societies.
Inequalities in income and wealth at global and national levels are striking. According to the
UN-sponsored World Institute for Development Economic Research in 2000, 1% of adults in
the world owned 40% of the world’s wealth 3 and the richest 10% owned 85%. In contrast,
the bottom 50% of the world’s population owned only 1.1% of global wealth. Geographical
3
In this study wealth was defined as what people owned, such as property, land, shares and cash minus their debts or what
they owed.
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SEKN Final Report February 2008
inequalities in the distribution of wealth are equally striking, with households in North
America, Europe, Japan and Australia owning around 90% of global wealth. Sharp
inequalities are also apparent within global regions. In Latin America, for example,
inequalities in income and wealth have grown dramatically since the 1970s and the continent
now has the highest Gini coefficient in the world. In European countries the income of the
richest 10% of the population is between 20% and 30% higher than the poorest 10%; in
Latin America the incomes of the top 10% are between 200% and 300% higher than those of
the bottom 10% (CEPAL et al, 2007: 28-33).
These global inequalities are replicated at country level. In the UK, for example, the share of
national wealth owned by the richest 1% of the population grew as a proportion of the
national share from 17% in 1991 to 24% in 2002, while the share of the bottom 50% fell from
8% to 6% over the same time period (Lansley, 2007). There is also evidence of growing
geographic polarisation across Britain, with rich and poor living further apart and the poorest
and wealthiest households increasingly segregated from the rest of society (Dorling et al,
2007).
The World Bank (2007a) argues that the numbers of people experiencing extreme poverty
(defined as living on less than US$1 a day) fell between 1981 and 2004 from nearly 1.5
billion to just under 1 billion. But there are regional variations: in Latin America, for example,
the number of people living in poverty increased from 136 million to 205 million between
1980 and 2006, although the proportion decreases from 40.5% to 38.5%. Fifteen per cent of
the population of the region are officially defined as indigent: they do not have enough
income to meet basic needs. Sub-Saharan Africa (SSA) is the world’s poorest region, with
half of its people living on less than US$1 per day, and during the 1990s both average
income in the SSA region and the percentage of the people living below the US$1 poverty
line scarcely changed (Kakwani, et al, 2005).
The World Bank definition of severe poverty – at US$1 a day - is also problematic. For
example, the UNDP’s International Poverty Centre argues that the severe poverty line
should be set at US$1.50 a day to reflect increasing costs of basic necessities (Kakwani and
Son, 2006). Using this figure the proportion of the world’s population experiencing extreme
poverty was 36% and not 21% in 2001 and the numbers of people in severe poverty rose by
800 million to around 2 billion. Additionally, although the World Bank has argued that two
elements — material and social needs — should be combined in the measurement of
poverty, research to establish social needs has not been forthcoming and subsequent
measures used by the Bank have only updated the cost of basic material needs, ignoring the
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need for resources to meet changing patterns of consumption and roles and obligations. If
these are included the scale of world poverty is dramatically greater than World Bank figures
suggest.
However they are measured, no global region is free of inequalities and poverty. In the
European Union, for example, it is estimated that 15% of the population are at risk of poverty
and in the UK 10.4 million people (18% of the population) were living in households receiving
less than 60% of the median income before housing costs and 12.8 million (22% of the
population) after housing costs in 2005/06 (HBAI team, 2007).
What then of the causes of poverty and economic inequality? Despite the persistence, over
centuries, of discourses which blame individuals and cultural practices, the weight of
research clearly suggests that the causes of poverty and inequality are embedded in the
structures of social systems and relationships – in exclusionary processes – and not in
individual inadequacies. At both global and local levels history has played a part. In
LEDCs, for example, colonial systems left economies structured for the expropriation of
natural resources to support growth in the northern hemisphere, rather than building
infrastructures to support local social and economic development. Enduring inequalities in
high-income countries also have their roots in historical inequalities in patterns of social and
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economic development. Geography also plays a part: recent research has shown how
location near to harbours, climatic conditions and associated patterns of infectious diseases
have all helped to shape inequalities in social and economic development and in health both
globally and locally (Sachs et al, 2000).
The legacies of history and the influences of geography have been compounded by
contemporary patterns of trade. Globalisation and the pursuit of free trade, for example,
have been associated with an expansion of poor quality jobs in the formal sector as
standards of labour practices are not formally included in world trade agreements and most
initiatives to promote greater corporate responsibility for conditions of labour are voluntary
and poorly monitored. There has also been an increase in people working in the informal
sector where labour conditions are particularly problematic. As a result, around 25% of the
employed labour-force globally is defined as living in poverty and the proportion of the
labour-force working in the informal non-agricultural economy ranges from 20% in developed
economies to over 55% in Latin America, between 45% and 85% in Asia and 80% in Africa.
In Sub-Saharan Africa and South Asia 89% of the employed population earn less than US$2
per day 4. Having no work at all – either poorly paid or informal – is also an important aspect
of the economic dimension of exclusionary processes in all regions of the world. As
Forrester (1997) writes about France, people are obliged every day to search for a job which
does not exist. Low productivity in the agricultural sector is a particularly important barrier to
poverty reduction in low-income countries. Despite rapid urbanisation in all countries, UN
figures suggest that in 2005 more than half the population in less developed regions still
lived in rural areas and in the least developed countries this was estimated to be more than
70%, and extreme poverty is concentrated in rural areas.
The powerful forces driving poverty and inequality through global trading relationships are
related to and exacerbated by other factors. Unsustainable models of economic growth and
trade, for example, are contributing to environmental degradation lowering living standards in
rural areas. These problems are aggravated in low-income countries by population growth,
fuelled in turn by poverty. Climate change resulting from the pursuit of economic growth is an
increasingly important driver of poverty and inequality – affecting most severely the poorest
and most vulnerable people and areas in the world. This in turn is leading to conflict as
demand outstrips the carrying capacity of the land, as in Dafur. Conflict, however it begins,
generates greater poverty and inequality, reducing per capita income and displacing large
4
Globalisation and Employment Conditions Knowledge Networks’ final reports
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SEKN Final Report February 2008
umbers of people from their homes and livelihoods. These processes, underpinned as they
are by gender disparities in rights, entitlements and capabilities, also drive gender
inequalities in the experience of poverty.
The policies of global multilateral agencies not only failed to address these drivers of
inequality and poverty but have actually deepened exclusionary processes. For example, the
structural adjustment policies of the World Bank and the IMF in the 1980s and 90s, and
neoliberal policies aimed at supporting economic growth, were responsible for significant
increases in the numbers of people living in poverty, cuts in basic services such as health
and education and a shift towards selective rather than universal approaches to poverty
reduction. Many national governments have either been unable or unwilling to resist the
conditions imposed by these agencies. More generally, weak systems of governance and
corruption also contribute to the continuation and deepening of inequalities around the world.
Whilst these may be a particular feature of some low income countries, recent corruption
scandals in high income countries remind us that no countries or regions are free of such
problems. All these exclusionary processes are grafted on to and reinforce systems of
discrimination operating within and between national states along lines of gender, class,
race, age and ability.
Don’t ask me what poverty is because you have met it outside my house. Look at the
house and count the number of holes. Look at my utensils and the clothes that I am
wearing. Look at everything and write what you see. – Kenya 1997
Poverty is humiliation, the sense of being dependent on them, and of being forced to
accept rudeness, insults, and indifference when we seek help. – Latvia 1998
In my family if anyone becomes seriously ill we know that we will lose him because we do
not even have enough money for food so we cannot buy medicine. – Vietnam
1999(Source: Narayan et al, 2000)
The growing recognition of the complexity and multidimensionality of poverty and the shift
towards concepts related to social exclusion is captured in the comments below taken from
the Government of Mozambique’s Action Plan for the Reduction of Absolute Poverty
(PARPA) for 2006-09:
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exclusion from society, powerlessness, vulnerability, and others. The definition used
for PARPA II is the impossibility, owing to inability and/or lack of opportunity for
individuals, families, and communities to have access to minimum basic conditions,
according to society’s basic standards.
The UN estimates that in 2004 17% of the world’s population (1.2 billion people) did not have
sustainable access to a safe water supply and 41% (2.6 billion people) did not have access
to decent standards of sanitation. Worldwide, an estimated 1.3 billion people have no access
to effective and affordable healthcare, while annually an additional 150 million people in 44
million households face financial catastrophe as a direct result of having to pay for
healthcare. 5 In 2001-2003, 17% of the world’s population and 30% of people living in SSA
were undernourished – 830 million people in the developing world (Watkins, 2006).
However, stark as they are, numbers do not capture the complexity of the experience of
extreme poverty: when people living in extreme poverty talk about their experience, assets
and capabilities are more important than income. The absence of physical, human, social,
political and environmental assets is linked to vulnerability and exposure to risk. A lack of
access to basic infrastructure – particularly roads, transport, water, and health facilities – is
critical. Lack of basic skills, such as literacy, increases vulnerability. The psychological
aspects of the experience are also important: the absence of voice, power, and
independence, the vulnerability to exploitation; rudeness, humiliation, and inhumane
treatment by society; and the pain associated with unavoidable violations of social norms
and inability to maintain cultural identities, for example, by participating in traditions,
festivals, and rituals. Together these experiences can lead to a breakdown of social relations
(Narayan et al, 2000). Given the scale and nature of the problem it is perhaps not surprising
that the primary focus of much policy and action is on groups experiencing extreme poverty.
However, from a relational perspective the causes of extreme poverty and therefore the
most sustainable solutions are to be found in the relationship between poverty, affluence and
unequal power within and between countries and global regions.
Focus on Bangladesh
Bangladesh is one of the poorest, most disaster-prone countries in the world: here also there
are inequalities with extremes of poverty found, for example, in the temporary alluvial islands
- or chars - deposited by the country’s three major rivers, and in informal settlements in
urban areas. Bangladesh is 137th out of 177 countries on the 2006 UN Human Development
Index (Watkins, 2006) and 167th out of 209 countries for gross national income (adjusted for
5
(OIT-OPS, 1999).
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SEKN Final Report February 2008
purchasing power parity) according to the World Bank per capita statistics (World Bank
2007b). Half of the population is poor, 31% is chronically poor and almost a quarter (23%) is
living in extreme income poverty (Sen and Hulme 2004). Female-headed households are
disproportionately affected: more likely to live in poverty, less likely to own their homestead,
less likely to include literate adults, and more likely to experience under-five mortality
(BRAC, 2004). Population density, at 1001 per square kilometre, is the world’s highest for
developing countries. Nevertheless, around 75% of the population lives in rural areas – a
figure which is decreasing with rapid urbanization (Streatfield, 2007) and the depth and
severity of poverty are greater here, even compared with the dire conditions of Bangladesh’s
informal urban settlements.
Despite significant gains in recent years, social indicators continue to paint a grim picture of
the impact at country level of powerful exclusionary forces: under-five mortality is 77 per
1000, life expectancy 63 years, and adult literacy 52% for men and 33% for women
(Watkins, 2006). Populations living in extreme poverty have little or no asset base, are
highly vulnerable to shock (e.g. natural disaster, illness requiring prohibitively expensive
treatment or the death or disability of an income-earner), and mainly depend on wage-labour
for survival.
Every year, as the melting snow and ice from the Himalayas combines with the monsoon
and runs into the Gangetic Delta of Bangladesh, the rivers rise. When the rivers flood the
temporary alluvial islands – chars - the people living there are forced to leave their houses
and fields. When the tides recede erosion can pull land and houses into the rivers. In
addition to annual flooding, tornadoes and cyclones occasionally cause havoc on the coastal
chars. Despite these known hazards an estimated 5 million Bangladeshis live on the chars,
accepting loss and uncertainty as part of their lives.
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When at last our houses become decent and the land grows fertile, erosion comes
and we have to begin all over again, explains Hayatun, a woman from Rulipara char.
(Saussier, 1998)
During the floods, the challenges of storing and cooking food, accessing safe water and
maintaining sanitation often lead to malnutrition and diarrhoea. Because of the remoteness
of the chars only minimal and relatively poor public services, such as health facilities and
schools, are available. Travelling to the mainland for necessities or emergencies can be very
difficult during the wet season. Private boats link chars to the mainland, but their timing and
frequency is erratic, and the cost of a charter boat during an emergency is beyond the reach
of most households (Ashley et al, 2000). During the dry season when much of the river dries
up people must walk for long distances on a scorching sandy riverbed. In addition to extreme
material poverty and environmental vulnerabilities, people living on the chars have minimal
access to opportunities to enhance their capabilities and resources, further contributing to
the chronic, intergenerational transfer of extreme poverty.
In Bangladesh informal settlements are typically built on empty government land or private
vacant land, with low-quality housing and very high population density. They are usually
located in marginal areas poorly served by public services or utilities and vulnerable to
natural disasters. The flimsy housing materials in the informal settlements provides little
6
This section draws from Rashid (2007): Strategies to reduce social exclusion among populations living in slums in
Bangladesh, a background paper for the SEKN.
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SEKN Final Report February 2008
protection from fire or monsoon rain 7, often leading to their collapse. Many are built on waste
or polluted spaces subjecting residents to noxious fumes (Islam et al, 2006), with abysmal
sanitation. Uncollected garbage and excreta are dumped in drainage ditches, which clog
during rainstorms, leading to flooding and spreading of waste. Latrines are few so children
use alleyways as toilets. At night women also use the alleyways, preferring to avoid the risk
of rape or sexual harassment associated with walking though the area at night. Other public
infrastructure such as schools, health clinics, water and electricity are rarely available
because these informal urban settlements are considered illegal establishments, so
residents experience a constant threat of eviction.
Eviction
For Madhia and Razia’s [adolescents] mother, the move to a new ‘slum’ on the outskirts of Dhaka
city after eviction from their previous informal settlement posed many problems. They had left behind
old networks and did not know of anyone in this new settlement. The locality was well-known for
crime and violence but rent was extremely cheap. The single mother worried about sexual abuse of
her daughters but needed to work long hours outside the home, to support her family. She usually
locked them inside their rooms and left for work. . (Rashid, 2005)
The government’s National Housing Policy acknowledges the rights of the urban poor to
housing, shelter, and food (ASK, 2000; Ministry of Works, 1993). However, despite a High
Court Order forbidding the eviction of people living in informal settlements without
rehabilitation, they continue to be demolished by successive governments (Daily Star, 1999).
Continued pressure from local human rights organizations, local and international agencies
and large-scale protests by people who live in these settlements have largely been ignored,
with no real effort by the government to help the urban poor. It is reported that around 135
settlements were cleared between 1975 and 2005 and the eviction in Agargaon (one of the
largest informal settlements in Dhaka city) affected an estimated 40,000 residents in 2004
(Barrett and Dunn, 2006). The threat of eviction is problematic not only because of the ever-
present threat of one’s home and possessions being destroyed but also because people
who live in informal settlements and NGOs hesitate to invest limited resources in improving
livelihoods and living conditions because of the very real fear of losing their capital
investment.
Opportunities for upward mobility among the extreme poor are few. Available paid labour
activities include rickshaw-pulling, leather tanning, rag-picking, working in the brick kilns,
brick breaking and sex work. These activities all expose the labourer to increased risk of
7
The term ‘informal settlement’ is used to avoid the derogatory associations with the word ‘slum’ and its
translations: an area that combines to various extents inadequate access to safe water, sanitation and other
infrastructure, poor structural quality of housing, overcrowding, and insecure residential status.
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SEKN Final Report February 2008
health shocks, and have limited opportunity for personal development. A recent study of 400
rickshaw-pullers found that 75% had experienced at least one financial crisis in the past five
years and 67% had had a health-related crisis. Sickness, disease and death were common.
Twenty nine per cent of rickshaw pullers reported the death of a child (Sen and Hulme
2004). Both the char populations and urban dwellers living in informal settlements face
extreme environmental hazards and basic infrastructure which could help them lift
themselves out of extreme poverty is absent. Both populations are aware of their
vulnerability to numerous types of financial shocks – health crisis, theft, eviction, extortion -
that will almost inevitably drive them deeper into poverty.
Case Study 2: Social Exclusion, displaced people and the logic of the camp
The concept of ‘displacement’ typically includes people displaced from their land and
livelihood by complex interactions between exclusionary processes including economic
processes, conflict, discrimination, genocide, environmental degradation and climate
change. It also includes ‘stateless’ people who, lacking formal identity documents such as
birth certificates, have never had the right to reside within the boundaries of a nation state.
Finally, and less usually, ‘displacement’ is used in this report to refer to people living in
informal settlements around the world: displaced from the mainstream of their society and
despite having formal citizenship status, denied the rights other citizens take for granted.
The scale and experiences of displaced people - the stateless, refugees, asylum seekers
and residents of informal settlements – dramatically illustrate the complexity of exclusionary
processes and their impact both globally and locally. As Diken and Lausten (2005) argue,
such people live in a ‘state of exception’ where the laws applying to citizens are not
recognised. This is nowhere more evident than in the camps that characterise the 21st
century. Moorehead (2005:156) writes of the refugee camps of Guinea, along the border
with Liberia:
They exist along the very margins of life, whether inside the camps or outside, so
poor that, in a literal way, they have nothing. Most of them do not even have a
bucket, and they think about one and talk about one with longing. […] Poverty is very
hard to describe. It is an absence, a nothingness not easy to put into words. But the
poverty of camp refugees is about more than not just having things; it is about
controlling one’s own life. Their poverty curbs and crushes all hope and expectation.
Kuankan’s refugees are destitute in possibilities.
But as East argues (2007) ‘camps’ are not necessarily a physical or geographical entity and
in an important sense they are becoming a routine feature of life around the globe. In the
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SEKN Final Report February 2008
United Kingdom, for example, asylum seekers’ live in a ‘state of exception’ in another form of
camp:
Living on small amounts of support payments or even food vouchers with no cash
allowance, which pushes the asylum seeker out of the normal functioning of system;
to be prevented from finding paid work; living according to the government’s choice
of residency; and minimum geographical mobility (Diken and Lausten, 2005: 88).
Similarly, residents of informal settlements around the world, such as the favelas of Brazil,
also live in a ‘state of exception’ denied the rights available to other members of their
societies by the dictatorship of drug gangs, unofficial militia and police.
According to the Office of the United Nations High Commissioner for Refugees (UNHCR
2007), at the end of 2005, the number of people with ‘official’ refugee status, or protected or
assisted by the UNHCR because they were at risk, stood at 21 million. A year later this had
increased by 56% to 32.9 million. The single largest increase (contributing to this figure of
32.9 million) has occurred among internally displaced persons, estimated at around 12.8
million. The 2006 figures for stateless persons also show a marked increase compared to
the figures for 2005. By the close of 2006, there were an estimated 9.9 million refugees
globally. Of the people recognised as refugees by the UNHCR, around half were being
supported through UNHCR assistance programmes, of which the vast majority were living in
African and Asian countries, often in refugee camps. The countries with the highest number
of refugees in 2006 were Pakistan and Iran, who together accommodate 20% of the world’s
refugees. The countries of origin of the greatest number of refugees in 2006 remained
Afghanistan, followed by Iraq. The three other main source countries were Somalia, the
Democratic Republic of the Congo and Burundi - but these exclusionary processes are
evident in all regions of the world. Official figures such as these do not, of course, include
the millions of people in informal settlements displaced from the mainstream of their own
societies despite having formal citizenship.
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SEKN Final Report February 2008
Figure 4 seeks to illustrate the impact of exclusionary processes associated with the
experience of displacement. Initially, people displaced from their land by conflict experience
dramatic deterioration in their resources and capabilities across all dimensions. Women from
rural areas represent almost half of displaced people (47%) and, together with children aged
15 or less, they bear the brunt of the displacement, suffering not only human rights abuses,
but also material deprivation and political and cultural discrimination. There are high
numbers of female headed households amongst displaced people, with dependency ratios
higher than the national average for such households (Ojeda and Murad, 2005). When they
arrive in urban areas, displaced people are forced to live in high risk areas, on the fringes of
the city or in precarious living conditions. They have low educational attainment with high
drop-out rates, low or no employment, high rates of teenage pregnancies and 93% of
displaced households live below the poverty line (Econometría-SEI, 2005; Ibañez et al.,
2006). These households have poor health outcomes, with a higher burden of disease and
worse nutrition status than poor people in non-displaced areas (PMA, 2003)
Although the Colombian state developed a policy addressing the precarious situation of
displaced people after 1997 in response to a Constitutional Court ruling, inequalities remain.
Displaced people are required to register with specific authorities (civil and military) before
they can access services. After registration they are eligible for the subsidised means-
tested programs providing access to health services and education as well as conditional
cash transfers available to all local residents living on low incomes.
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opportunity to integrate socially. However, registration also makes them more visible and
puts them at risk of discrimination and victimisation. It is not possible to put figures on the
numbers not registering because of these risks but many do not and hence do not receive
the resources and services established by the State and are pushed further towards the
margins of society (Hernández et al., 2006).
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Political
Political Political
Social Economic
Yes
No
Social Economic
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SEKN Final Report February 2008
In April 2007 Seth Mydans 8 a journalist with the International Herald Tribune reported on the
circumstances of the millions of stateless people around the world: ‘citizens of nowhere,
forgotten or neglected by governments, ignored by census takers’. He catalogued the
extreme poverty experienced by these people driven into statelessness by war and conflict,
racial and ethnic tensions and what he refers to as ‘the quirks of history’. As Mydans
highlights, with no citizenship rights people who are the most vulnerable in the world have
few advocates: they are frequently subjected to exploitation, forced to work for little if any
reward and persecuted for their religious beliefs. Whilst human rights groups are making an
important contribution, they tend to focus on the abuse suffered and meeting basic needs
rather than addressing statelessness as the primary cause of the problems. The largest
group of stateless people are in Thailand but they are spread around the globe and the scale
of the problem is increasing. Mydans describes the ambitious programme established by
the government in Thailand to determine its stateless people's rights to citizenship but DNA
tests and initiatives to establish effective population registration systems will only ever be
partial solutions. More sustainable solutions to the global tragedy of statelessness require
an end to war, racial conflict and discrimination around the world.
8
International Herald Tribune on April 1st 2007.
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We were 9 men, two women and two children. At about 9.30 a.m. they transferred us
to the Dokki police station. There an officer with an eagle and a star beat us up
himself. They took us downstairs to a basement. Everyone passing by would beat us
with a stick on our backs or shoulders. We were tied, each two or three together. In a
small room, with a semi-rounded platform, they forced us on top of the platform with
our faces towards the wall. They started searching us. They insulted us and insulted
our country. They called us black and abused our mothers with obscenities. Then
they closed the door and left. After about 5 minutes about 20 men entered the room.
They took off their top clothes. They got razors out of their mouths and started
beating us. We withdrew into the toilet and this is how we remained: them in the
room and we on top of each other in a very small toilet. After about three hours, the
police started to call for us, one by one, for the interrogation. Each of us signed a
paper where there was only one question and one answer: What is your name? Then
a police truck came and took away the men to the prosecution.
On the 6th of April we went to court, which ordered a 15-day extension of our
imprisonment. The lawyers did not know about the date and so none of them was
there. We returned to the Giza police station and remained there, in the same
situation, for another 15 days. They did not bring us any food. We had no money on
us and lived on the charity of the other inmates. We returned to the same judge on
the 19th of April. He commented: “You have cleaned up and have gained weight!! It
seems that prison is good for you”. This time we had a lawyer with us, who asked for
our release. The judge extended our imprisonment for another week. We were
summoned to the judge for the third time. The judge told us, and these are his exact
words: “You must stop politics and never go to UNHCR again. If you do return to
UNHCR you will be sentenced to 6 years in prison and will never see the sun again”.
We were returned to the Giza police station. They photographed us and took our
finger prints and we were released four days later, to the state security intelligence
office in Sheikh Zayed city. They blindfolded us for 9 hours. They were terrifying and
terrorizing us.
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These figures do not begin to capture the regime of terror to which favela residents are
subjected. Twenty-two years after the end of military dictatorship, people living in Rio’s
favelas live in a ‘state of exception’ comparable to that experienced by refugees with their
fundamental rights – formally guaranteed by the constitution – routinely violated by armed
groups trafficking in drugs, the militia (informal security) and the police. These ‘dictators’
govern the favelas: they judge what is good or bad, dictate rules and set punishments for
failure to obey, extending their influence into all aspects of social, political, cultural and
economic life.
Torture, execution, and exile are common punishments in the favelas. Public torture, widely
used against political activists during the military dictatorship, continues to be used by the
favela dictators to instill fear in residents. Beatings are widespread: for domestic violence,
theft or a simple misunderstanding with the wife of a drug dealer. People are suffocated with
plastic bags, shot thought their hands, knees or feet or lacerated with swords, axes and
knifes. Gang members who do not obey the rules are punished in the same way.
There is no way to estimate the number of executions because the bodies disappear –
removed to clandestine cemeteries. This tactic, used effectively by Brazil’s military
dictatorship, undermines the formal legal process – with no evidence of a crime no culprit
can be identified and charged. In the fourteen years from 1993 until 2007 the favela
‘dictators’ have been associated with the disappearance of more than 7,000 people –
compared to 136 people reported missing during the 21 years of the military regime
according to the NGO Tortura Nunca Mais [No More Torture].
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On May 23, 2006, Sebastião da Silva Marques, 45 years old, left the house to buy bread.
Two young armed drug-trafficking "soldiers" accused him of being "X-9" (police informer)
and took him to their leader in a favela to the West of the city. Condemned to death he was
forced to dig his own grave. According to a witness, in exchange for US$ 1,200 the police
had told the drug dealers that Sebastião was an informer.
On August 10, 1993, Jorge Carelli an employee of the Oswaldo Cruz Foundation (Fiocruz)
was using a public phone in Manguinhos where he lived when civil policemen mistook him
for a criminal. Carelli was taken away in a police car and has never been found. Advocacy
by officials of Fiocruz led to a police investigation which found traces of blood, hair and a
bullet hole in the car. Twenty two police men were prosecuted for the murder of Carelli, but
all were acquitted. In 1999, the state government accepted responsibility for his death and
agreed to pay a monthly pension and compensation to Carelli’s parents.
"In the favela, you lose your children for trafficking or to the police. Young criminals of Barra [
a neighborhood where wealthy families live], when caught by the police have good lawyers
and are soon released or go to rehabilitation clinics. Our children are executed”: Joel, 61
years old, street market worker, who sons have all been murdered.
An incalculable number of people have been exiled: forced to abandon their homes by drug
dealers or the militia just as political activists were forced to leave the country during the
military dictatorship. At least two hundred families were expelled from Vigário Geral when
the traffickers of Parada de Lucas invaded the community. Reflecting this situation, the rate
of homicides among young people aged 15 to 24 years living in Rio’s favelas in 2007 was
seven times higher than residents in other age groups and three times higher than young
people living elsewhere in the city.
Wallace, 13 years old, was in 5th grade. He shined shoes and dreamed of being a football
player. In 2004 he went to play with friends and was found dead in a drain. His sister
explained what had happened. The police had approached the boys wanting information
about traffickers. "My brother said he was not a bandit, but the police called him a black boy
and shot him in the head with his rifle. The next day I found the brain of my brother around
the floor, holes in the walls of the bullets and lot of blood”.
In Morro da Formiga, Paulo Andre da Silva, a community leader, refused to pay a fee to the
drug dealers. They beat him then executed him in front of the family. The body was burned
in a pyre made of tyires. The same had happened with Ronaldo da Conceição, another
community leader in the favela: killed and burned on top of the hill in August 2000.
The journalist Tim Lopes, from TV Globo, disappeared on June 2, 2002, while investigating
complaints from residents of Vila Cruzeiro, Penha of drugs being sold at a dance and
prostitution of minors. Caught with a micro-camera by members of the local drug gang, he
was taken to the top of the hill, "judged" and sentenced to death.
The homes of residents of the favelas are frequently invaded by traffickers, militiamen and
police without court orders.
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In the middle of a night of September 2006, in one of the largest favelas of the north side of
the city, ten bandits armed with rifles, grenades and machine guns ordered Antonio to open
the door. Frightened, Antonio, got his wife and three children out of bed and waited in the
corner of the room while the criminals searched his home looking for members of a rival
gang expelled from the favela weeks earlier. Antony describes what happened: "The guy
was obviously on drugs. He carried grenades tied to his waist and a machine gun. They
stayed around ten minutes and turned everything upside down. When leaving they said that
we shouldn’t leave the house. I feared they would slip and drop the grenades or start
shooting. I felt humiliated. Sometimes I want to cry because I can’t do anything, I feel
powerless".
Nowhere is safe. Complexo da Maré, a house which served during the day as a nursery for
270 children, was used during the evenings by a drug gang to pack the marijuana and
cocaine they sold. The police found out and surrounded the nursery, shots were exchanged
and two of the gang died in the nursery.
The ‘borders’ established over the years of wars between rival drug traffickers, militias and
police undermine residents’ right to freedom of movement and barricades and curfews are
common. In the favela of Praia de Ramos the militia has erected walls and gates in an
attempt to prevent drug traffickers from neighbouring favelas from entering but also
restricting the movement of the 5000 inhabitants. After 10 p.m. the gates are patrolled by
members of the militia dressed in black and inhabitants are only admitted with identification.
Physical barriers and armed conflicts disrupt basic public services: telephones are not
repaired, areas have no post for weeks and residents fearful of leaving their homes do not
use local health services. Armed conflict between gangs, militia and police in Complexo do
Alemão affected around 4,800 children, who either had no school to attend or were
transferred to a single school, where thousands of students went to study for only two hours
a day.
The reach of the dealers and militia often extends far beyond drug dealing and favela
security to control of all aspects of life. They censor the music people can listen to, tap
telephone calls and even dictate the colour of the clothes people can wear because they
identify certain gangs. In some favelas they control the sale of cooking gas (preventing
legitimate gas deliveries) and clandestine cable TV connections. They arbitrate in feuds
between neighbours and family members, forbidding residents to call the police, prevent
residents forming community associations freely and determine which community candidates
will be put forward for election to local government posts.
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When the militia took charge of the Favela Kelson's, in Penha, they expelled the president of
the resident association and threatened him with death. In an interview with a local
newspaper a community leader said: "They expelled the drug traffic and today the
dictatorship of militia rules. They stole my dignity. They say that community leaders are
involved with drug traffic. I am asking the Group of Special Areas Police to intervene
because of the threat of many deaths and also to help reinstate me… I have done everything
officially and I am at risk but so far I have not been successful (...) 200 people were killed in
Kelson's”. A few days after this interview the community leader was kidnapped and
disappeared. Relatives testify that he was killed by the militiamen denounced by him.
The HIV and AIDS epidemic is both a cause and a consequence of exclusionary forces.
Although few parts of the globe have been left untouched, as Figure 5 shows, and with some
exceptions, it is those countries and social groups most affected by exclusionary processes
and experiencing the greatest social, economic, cultural and political disadvantage which
have been at greatest risk of infection. Once infected, people belonging to these groups
and/or living in these geographical areas are further disadvantaged because of limited
access to services for diagnosis and treatment. The disability and ill health arising from AIDS
and the stigma and discrimination associated with HIV status thus combine with other
exclusionary processes to exacerbate social, economic, political and cultural inequalities.
Despite progress being made in a small but growing number of countries, the AIDS epidemic
continues to outstrip global efforts to contain it, with no part of the globe left untouched
(UNAIDS, 2006).
Figure 5
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By the end of 2005, just over 38 million people were living with HIV, with an estimated 4
million new infections worldwide (UNAIDS, 2006). In the same year, almost 3 million people
died of AIDS-related diseases. More recently the UNAIDS is reporting a decline in the total
number of infected people to 33 million globally.
The key factors driving the epidemic in Southern Africa include poverty, culture, stigma and
discrimination. Poverty works through a myriad of interrelations including unequal income
distribution and economic inequalities between men and women which promote
transactional sex. The overlap of gender and socio-economic inequalities is especially harsh
in South Africa, where many women depend on social grants, remittances from male
partners and other kin, and other inconsistent and informal sources of income. All this has
further weakened women’s economic status, aggravating gender inequalities and
exacerbating their exposure to HIV risk (NEDLAC, 2006).
Gender inequalities in patriarchal cultures, where women are accorded a lower status than
men, have serious implications for choices women can make in their lives especially
regarding when, with whom and how sexual intercourse takes place (Meyer-Weitz et al.,
1998). Such decisions are frequently constrained by coercion and violence in women’s
relationships with men. For example, whilst male partners may have sex with sex workers or
engage in multiple relationships, their female partners or spouses may be unwilling to insist
on the use of condoms during sexual intercourse for fear of losing their main source of
livelihood. Many women are thus left unprotected and exposed to HIV infection.
HIV and AIDS is one of the most stigmatised medical conditions in the world. Stigma interferes
with HIV prevention, diagnosis, and treatment and can become internalized by people living with
HIV and AIDS (UNAIDS, 2006). HIV infection, as with other STIs, is widely perceived as an
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outcome of sexual excess and low moral character – rather than as a disease of poverty and
inequality. As a result there is a strong culture of silence and denial by people living with HIV and
AIDS because of fear of rejection and isolation by close relatives and the community at large
(Johnston, 2001). The woman quoted below describes how stigma and social isolation are
experienced: stigma is more severe for women than for men (Achmat, 2001).
I know personally I’ve had to put up with, ‘you can’t use our cups, you can’t use our
knives, you can’t use our forks, you have to bring your own stuff to the office, hmm, so
that you can…’ You know, you kind of start getting isolated by people. People don’t tend
to want to talk to you because of knowing what your status is and I think it is plainly
through total ignorance (Muslim woman living with HIV, Cape Town, South Africa).1
A vicious cycle of poverty and deprivation of social and basic needs leads to an increased
prevalence of HIV and AIDS. Increasingly young people are feeling the brunt of this
pandemic as they are forced to take leadership roles within the household: caring for parents
dying of AIDS and earning an income for the family. This often leads young people to turn to
risky sources of income, such as commercial sex work, as a means of supporting the family.
The young people themselves then become more vulnerable to HIV and any social
achievements in health and education efforts are reversed (UNDP, 2005). The impact of HIV
on young people will inevitably worsen if things do not change significantly. In Kenya, it is
anticipated that a 15-year-old will have a more than 60% chance of death from AIDS9.
Focus on Bangladesh 10
Bangladesh continues to have a low HIV prevalence rate: less than 1% of the general
population. The first known case of HIV in Bangladesh was reported in 1989, and the most
recent government data reports 874 people living with HIV, and a total of 240 AIDS cases
(NASP 2004; ICDDR,B, 2006). However the most recent serological surveillance data
indicate an epidemic for the first time in Bangladesh amongst a sub-group of male injecting
drug users (IDU). In just twelve months (2005/06) HIV prevalence in such male drug users
has increased from 4.9% to 7% in one city, and prevalence in one neighbourhood has
increased from 7.1% to 10.5%. This is just one of the indicators of the imminent danger of an
HIV and AIDS epidemic facing Bangladesh (NASP Sixth Round 2004-2005 11). These figures
are considered underestimates given that the surveillance system only covers most-at-risk
populations; voluntary testing and counselling facilities are limited, and high levels of stigma
9
US Census, www.hdr.undp.org
10
This section draws from: Khosla N. 2007. HIV/AIDS interventions in Bangladesh: What can the application of a social
exclusion framework tell usk SEKN Background Paper 11.
11 th
NASP Sixth Round. 2004-2005; National HIV serological surveillance,2004-2005 Bangladesh 6 technical report. NASP,
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surround HIV infection. There is little incentive for HIV testing because care facilities and
treatment for HIV positive people are extremely limited.
There is a limited discourse on protecting the human rights of those affected and infected by
HIV and AIDS but the majority of prevention efforts – at international, national and
community levels – tend to be epidemiologically-based, focussing on biomedical efforts and
changing behaviour to reduce high risk behaviours among the most at-risk sub-populations
such as commercial sex workers, injecting drug users, men who have sex with men,
transgendered hijiras and people living with HIV and AIDS. These interventions are attractive
because they directly target high risk groups and are readily measurable, for example in
terms of the number of condoms distributed or HIV information booklets produced and
distributed. However, these approaches subject targeted sub-populations to high levels of
stigma and social exclusion. They also allow the underlying inequities predisposing these
populations to HIV infection to be ignored, contributing to a continuation of the conditions
which forecast an HIV epidemic in Bangladesh.
Case Study 4: Social exclusion, discrimination and cultural and social identity
Discrimination on the basis of cultural, social and/or racial identity generates powerful
exclusionary processes. These exclusionary processes can be systematic and intentional -
resulting from policies which deliberately discriminate against members of a particular group,
community or society and embedded in formal institutions of the state, as in the case of the
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Apartheid regime in South Africa. This is also the case with proposed new policies in
Australia restricting the rights of aboriginal peoples. Discriminatory processes and practices
are deeply embedded in the operation of labour markets: for example, the majority
indigenous Tuareg in North Niger represent only 1% of upper management personnel and
15% of workers and employees in the uranium mining industry which has polluted their
traditional lands and thus compromised their livelihoods. Discriminatory processes may also
be sanctified by religion, tradition and cultural practices – as exemplified by India’s caste
system - and embedded in dominant social attitudes, behaviours and prejudicial practices.
They may also arise unintentionally: even policies aimed at addressing social exclusion may
inadvertently stigmatise and discriminate against people who are the targets of such policies.
For example, it has been argued that regeneration initiatives targeting disadvantaged areas
in the UK exclude and stigmatise groups living in disadvantaged neighbourhoods (Davies,
2006).
Many of the historic injustices affecting indigenous peoples and/or minority ethnic groups
have their roots in colonization. Although in some instances the interaction between
indigenous and non-indigenous societies led to mutual benefit and cultural transfer, typically
it involved dispossession of land and territory, environmental degradation, subjugation and
loss of the right to autonomous development, pressure to assimilate and at worst, genocide.
It has more recently been recognised that indigenous people – of whom there are an
estimated 370 million - often possess a unique body of cultural and environmental
knowledge, the preservation of which is important for global sustainable development. Yet,
this knowledge is devalued 12 and there are repeated reports of indigenous peoples being the
victims of bio-piracy, or the unauthorised use of their traditional knowledge and biological
resources.
12
The devaluation of ‘lay knowledge’ is discussed in SEKN Background Paper 7 with specific reference to indigenous
peoples in Australia.
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albeit low-paid, employed in the local government sector until technological innovations
supported with aid monies resulted in the casualisation of labour and increasing deprivation,
financial insecurity, and economic marginalisation. Violence and conflict are also closely
associated with discrimination and reinforce exclusionary processes. The UNDP (2007)
estimates that three-quarters of all conflicts have an ethnic or religious dimension. These
typically involve restrictions on the economic and political rights of indigenous peoples and
minority ethnic groups and the suppression of cultural identity.
On rainy days, our existence was absolutely miserable. We were allowed to enter the
village only through the byways, and these would be all slushy with mud when it rained.
The outcasts and village people would squat on either side of the path, defecating. Rain
water, mixed with faeces, stagnated in puddles on the path through which outcasts, field
labourers and rice planters had to pass. Our legs would itch, infected with scabies. Later, at
night, red ants would discover the wounds and feed on them. Oozing pus, the discoloured
skin of our legs would resemble a leper’s. From: Karikalan I (2002) Oorakali. In Basu T (eds)
Translating caste. Stories, essays, criticism. New Delhi: Katha
13
2001 India Census.
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This is an edited extract from the 2006 report by Mr Alvaro Gil-Robles, Council of Europe
Commissioner for Human Rights, on the human rights situation of the Roma, Sinti and
travellers in Europe.
There is a lot of prejudice and discrimination against Roma. We find it hard to do things
that others take for granted. We encounter problems because of who we are every day.
Our government turns a blind eye to racial crimes committed against Roma. Quite often
we have problems with the police, they suspect we all must be criminals. We don't want
to be given preferential treatment, we just want the same opportunities as everyone.
The Roma are a Pan-European minority comprising approximately ten million people. Their
history and culture are integral to European history and culture. However, the general
perception is often quite different: even in countries where the Roma have been living for
centuries they are frequently viewed by the majority population as foreigners in their home
countries. In the most horrendous manifestation of persecution, an estimated half a million
Roma were exterminated in the Holocaust. This history has resulted in a loss of confidence
in the state authorities and society as a whole, pushing many Roma communities to isolate
themselves from the rest of society as a measure of self-protection. Human rights concerns
faced by Roma in Central and Eastern Europe have attracted attention in recent years –
partly due to the accession process to the European Union. However, there has been less
attention given to the situation of Roma in Western Europe where they continue to
experience prejudice and discrimination.
In many countries health indicators such as life expectancy, child mortality, rates of infection
and chronic diseases among Roma/Gypsy communities reveal dramatic inequalities
compared with majority populations (UNDP,2002). Lack of access to healthcare contributes
to the poor health of Roma people, in large part due to lack of identity documents including
birth certificates. Problems are compounded by prejudiced attitudes amongst service
providers with widespread reports of health professionals refusing to provide treatment or
services even in universal services such as the UK’s National Health Service (European
Monitoring Centre on Racism and Xenophobia, 2003).
In terms of wider social determinants of health, despite the availability of funds evidence
suggests that local authorities often fail to provide water, electricity, sanitation, transport links
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and improved housing to Roma communities. Access to public housing may also be
restricted by the imposition of conditions - for example, Roma people are less likely to be
able to reach minimum educational levels than other groups. School non-attendance and
school dropouts continue to be unacceptably high among Roma children in many EU
countries, including the UK, and have even increased during the past ten years. While
poverty and, in certain communities, traditions create additional barriers to education,
discriminatory practices and prejudices and lack of transport are major contributory factors.
In countries as diverse as Slovakia, Finland and Denmark Roma children are frequently
placed in special classes without adequate psychological or pedagogic assessment and
follow a reduced curriculum. For example, in Slovakia, in some regions 80% of Roma
children are in specialised institutions and only 3% enter secondary school. This segregation
reduces Roma children’s chances for further education, and their employment potential
increases stigma, denying them and non-Roma children the opportunity to know each other
and to learn to live as equal citizens.
Only in the last few decades of the 20th century, in response to indigenous movements
across Latin America, have political constitutions begun to give formal recognition to cultural
diversity. However, despite this formal progress, there remain many barriers to genuine
equal inclusion of indigenous people, and their right to cultural autonomy continues to be
severely restricted. Stavenhagen (2007), a UN special envoy, argues that these
communities have suffered from a process of “cultural encapsulation” or systematic isolation
which has driven these peoples into situations of extreme deprivation and systematically
excluded them from traditional territories.
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Indigenous people have poorer access than the descendents of colonizing nations to goods
and services including food, housing, health, education, water and sanitary infrastructure
and these inequalities are even greater for women (BID, 2004). They are over-represented
amongst those living in poverty in all countries in Latin America, with women particularly
severely affected.
Indigenous people in Latin America are resisting these exclusionary processes. Their social
movements have produced formal political change and they are establishing culturally
appropriate services. For example, indigenous schools can have positive impacts on
educational achievements but coverage of these services is very low in Latin America, and
indigenous children have the lowest rates of education in all countries – compounding their
disadvantage into the future. Different models of healthcare have also been established with
and by indigenous peoples with positive impacts on health outcomes. However, many of
these services have closed due to lack of official support and today health services for
indigenous people are typically part of government subsidized services provided for low-
income people. For example, in Colombia, indigenous organizations can organize their own
insurance schemes and deliver their own services under the umbrella of the national
subsidized insurance scheme, but they have to operate as commercial organizations in line
with the logic of the national scheme and there are restrictions on how they can invest their
resources. These restrictions privilege medical models which focus on individualistic curative
services - thus marginalizing the knowledge of indigenous peoples which focuses on
equilibrium between nature and human beings - and service models which emphasise the
wider social determinants of health (OPS, 2004). The same processes are highlighted in the
case study of Australian indigenous people included in SEKN Background Paper 7.
The most profound impact of exclusionary processes on Latin America’s indigenous people
is the progressive loss of their territories. Indigenous communities operate systems of
collective rather than private ownership of land – because land represents the ‘mother of
humanity’ and their collective welfare depends on its sustainable use. Globalization is
producing large scale exploitation of indigenous land for petroleum, oil palm and other bio-
combustible products threatening systems of collective ownership, decreasing the
production of food and displacing indigenous people to urban areas, threatening the security
of their communities (BID, 2004).
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Figure 6 below illustrates how the position of Latin America’s indigenous people could move
in different directions and to different degrees along the four dimensions of
inclusion/exclusion highlighted in the SEKN conceptual model (page 22) depending on state
action. This figure suggests that constitutional recognition of their collective citizenship in
almost all LA countries is likely to have led to greater cultural and political inclusion and
improved their social and economic positions. However, the figure also suggests that if
national policies do not protect the rights of indigenous people, exclusionary processes,
including those associated with globalization, will undermine these gains as indigenous
people are displaced from their lands and forced into precarious living and working situations
in urban areas.
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Constitutional
3. Conservation of collective land and
recognition
indigenous culture
Political
Political Political
Social Economic
Favourable
Unfavourable
Social Economic
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SEKN final report February 2008
The Human Development Index (HDI), for example, is a composite measure across
three dimensions of human development - length of healthy life, education and material
living standards - covers 175 out of 192 UN Member countries. Although it does not
include data on democracy, inequality or respect for human rights, it is a valuable tool for
looking at aspects of social exclusion around the globe and importantly focuses on the
relationship with aspects of population health. The UN Human Poverty Index 2, based
on an understanding of poverty as ‘primarily a denial of choices and opportunities for
living a life one has reason to value’ (Watkins K, 2006) provides a more detailed picture
of the impact of exclusionary processes operating in MEDCs in relation to financial
resources, labour markets, access to education and life expectancy.
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notably the Gini Index. One of the most frequently used comparative measures of
income inequality, the Gini index measures the extent to which the distribution of income
(or consumption) among individuals or households within a country deviates from a
perfectly equal distribution. A value of 0 represents perfect equality, a value of 100
perfect inequalities. This is an important measure from the perspective of the SEKN,
focusing attention on the unequal distribution of resources across societies rather than
only on the poor.
Other global data relevant to an understanding of social exclusion can be derived from
reports produced by the UN refugee agency (UNHCR), the UN Food and Agriculture
Organisation (FAO), the International Labour Organisation (ILO) and annual reports on
progress towards the Millennium Development Goals produced by the World Bank.
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Primary indicators:
1. Persistent at-risk of poverty rate
2. relative median poverty risk gap
3. long term unemployment rate
4. population living in jobless households
5. early school leavers not in education or training
6. employment gap of immigrants (national level measure)
7. material deprivation (to be developed)
8. housing (to be developed)
9. unmet need of care by income quintile (to be developed)
10. Child well-being
Secondary indicators: At-risk of poverty rate
1 At-risk of poverty rate
2. poverty risk by household type
3. poverty risk by the work intensity of households
4. poverty risk by most frequent activity status
5. poverty risk by accommodation tenure status
6. dispersion around the at risk of poverty threshold
7. persons with low educational attainment
8. poverty risk by accommodation status
9. Low reading literacy performance
Source: European Commission (2006) Portfolio of overarching indicators and streamlined social inclusion,
pensions and health portfolio, Brussels.
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whilst still dominated by indicators of income poverty, labour market relationships and
human capital (e.g. educational attainment) approaches to measuring social
inclusion/exclusion also include an idiosyncratic set of other measures including fuel
poverty, use of contraception, homelessness and several health-related measures
reflecting the more eclectic focus of UK social exclusion policy (DWP, 2006).
These case studies illustrate the greater depth and sophistication in the measurement of
social exclusion that can be achieved in country level studies, notwithstanding problems
of data availability. However, one-off studies like these are not able to monitor trends in
social exclusion/inclusion, which requires the routine collection of relevant data such as
that used in the Laeken indicators. When data are available, approaches to measuring
and monitoring exclusionary processes and their impacts can be more sophisticated at
the country level as they are not subject to the constraints arising from the need for
comparative data across countries or global regions. Some examples of country level
approaches to measurement are described below.
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Country level indicators are also being developed in Latin America. In Venezuela, for
example, Alberto Minujin (1998) has proposed a measure based on the idea of a
continuum from inclusion through vulnerable states to exclusion. Using data on social
and economic circumstances from the 1994 survey of households in Venezuela Minujin
developed a classification of households into three groups - “excluded”, “vulnerable” and
“included” – based on income level, years of education, type of employment contract and
duration of unemployment. Minujin’s classification allows for the possibility that
households can be poor because of their income but not excluded or vulnerable when
measured by other indicators (Minujin, 1998: 198). The ability of Minujin’s classification
to reveal the complexity of social exclusion is inevitably restricted by the limitation of the
data available – for example political and cultural dimensions are invisible in this
approach. More importantly, however, like other indicators described here the approach
is concerned to describe states rather than illuminating the processes generating these
states.
In Brazil, a group of scholars led by Pochmann (2002) has developed a Social Exclusion
Index based partly on the methodology used in the UNDP Human Development Index
but considering a larger number of dimensions of economic and social life. Table 3
shows the dimensions, indicators and weight attached to each indicator in the
construction of Pochmann’s Index. Using data from the National Census of 2000 they
produced an Atlas of Social Exclusion consisting of a series of maps illustrating the
situation in 5,500 Brazilian cities for each of the eight indicators. Applying the same
method to data from previous censuses allowed the group to consider the dynamics of
exclusionary processes operating both within and between these cities. The Atlas aims
to identify the regions of Brazil most severely affected by exclusionary processes over
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time and to influence the development and implementation of public policy in order to
reduce inequalities between areas.
More work has been done on the measurement of social exclusion in Europe than in any
other global region and there are also more theory-driven approaches to measurement
here than elsewhere. An example often cited is Paugam’s (1995) multi-dimensional
approach to the measurement of what he refers to as ‘social disqualification’ in France.
The Poverty & Social CASE measure of social The Bristol Social Exclusion Matrix (B-
Exclusion in Britain exclusion (Burchardt et al, SEM) (Levitas et al, 2007)
Survey (Gordon et al, 2002)
2000; Pantazis et al, 2006)
Dedicated cross-sectional Used longitudinal secondary Suggest range of secondary and primary
survey conducted in 1999; data from British Household data can be used to measures SE in 10
Representative sample of Panel Survey to measure domains:
1,534 UK households. Eight social exclusion along four Resources:
indicators used to develop dimensions of participation: • Material and economic
measures of four • consumption; • Access to services
dimensions of social • production (including • Social relationships
exclusion: social activities); Participation
• impoverishment; • political engagement; • Economic
• labour market; • social interaction • Social
• services; • Cultural, education,
• social relations. • Political civic participation
Quality of life impact
• Health & Well being
• Living environment
• Crime, harm, criminalisation
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Background Paper 1. A common feature of these approaches is that rather than relying
on a small number of idiosyncratic and separate indicators of social exclusion, they all
involve an attempt to theorise key domains of social exclusion and seek to describe the
relationship between them. These approaches use somewhat different labels for the
domains they identify. However, there is a shared focus on four ‘arenas’ of participation:
financial, labour market, services and social relationships whilst two of the three also
make explicit references to political participation. The Bristol Matrix also emphasises
cultural aspects of exclusion and the causal pathways between resources, participation
and outcomes. These indicators also give some – albeit limited - attention to the
relationship between social exclusion and health experiences.
The HDI also highlights significant inequalities between countries across and within
global regions. For example, people in Norway (at the top of the HDI league) are more
than 40 times wealthier than people in Niger (at the bottom of the league), live almost
twice as long, and enjoy near universal access to primary, secondary and tertiary
education, compared with only 21% of the population of Niger. Within Sub Saharan
Africa the HDI scores vary from around 0.6 in South Africa to 0.3 or lower in some
countries in West Africa. Variations between countries in converting wealth into
wellbeing are also revealed. Whilst some countries have an HDI rank far below their
income rank, others invert this relationship. In some cases these discrepancies result
from specific problems (e.g. HIV and AIDS in Southern Africa). In many others they are
likely to be the result of the failure to ensure access to basic living conditions (e.g. safe
water, sanitation) services such as health and education and social protection for
citizens.
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Finally, the HDI provides insight into trends over time in the nature and scale of
exclusionary processes and their impact. For example, since the mid-1970s almost all
regions have been progressively increasing their HDI score. East Asia and South Asia
have accelerated their progress since 1990 whilst central and Eastern Europe and the
Commonwealth of Independent States (the Baltic states), has also shown improvements
following a catastrophic decline in the first half of the 1990s. However, Southern Africa
is a major exception to this trend with HDI scores stagnating since 1990, partly because
of economic reversal, but principally because of the catastrophic effect of HIV and AIDS
on life expectancy.
The Laeken Indicators provide a more finely tuned picture of geographical inequalities in
exclusionary processes and their impacts but are available only for the EU area. Using
these indicators the EU has calculated the proportion of the population over 16 at risk of
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poverty in member states (European Commission, 2007). In 2004, the EU average was
16% but national figures ranged from 9% in Sweden and 10% in the Czech Republic to
20% in Ireland, Greece, Spain and Portugal and 21% in Lithuania and Poland. In most
countries, the proportion at risk of poverty was higher for women, the difference reaching
4 percentage points in Bulgaria and Italy, while at EU level the gender gap was 2
percentage points. Only in Hungary and Poland was the at-risk-of-poverty rate
marginally greater for men. The young have the highest at-risk-of-poverty rate, at 19%
for children aged 0-17, and 18% for the 18-24 age groups. The risk of poverty for
children is particularly high in Poland (29%), Lithuania (27%) and Romania (25%).
EU Member States with the lowest income inequality are also among the countries with
the lowest at-risk-of-poverty rate. The ratio of the income of those at in the bottom
quintile of the income distribution, compared with that of individuals in the top quintile,
was 4.9 for the EU in 2004. Member States with the highest disparities between those at
the top and those at the bottom of the income distribution are Portugal (with a ratio of
more than 8 to 1), followed by Lithuania, Latvia and Poland. There has been a common
trend for income disparities to increase (Begg et al, 2006).
This section has sought to identify and describe some of the existing sources of data
and formal indicators/measures that provide at least a partial window on social
exclusion. However, despite some obvious benefits there are a number of important
limitations associated with these data/indicators in terms of their ability to enhance our
understanding of the nature, scale and impact of exclusionary processes.
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methodological criticism. For example, the Laeken Indicators have been criticised for
their reliance on batteries of single indicators, which fail to distinguish between risk
factors and outcomes, and cannot prioritise or measure the interaction between factors.
These measures of ‘exclusionary states’ also tend to emphasise economic and social
dimensions, giving less attention to political and cultural dimensions.
Measures of the relationship between social exclusion and health outcomes are also
highly problematic, even setting aside the SEKN’s theoretical position that health is both
constituent and instrumental in relation to exclusionary processes. Taking social
exclusion as a state, inconsistencies in the ways in which social exclusion is defined and
measured, lack of an agreed set of indicators, and the inclusion in some measures of a
variety of health indicators as a component of or risk factor for social exclusion, rather
than an outcome of the experience, all make it difficult to ‘measure’ the impact of social
exclusion in health outcomes. Where health impacts are considered this typically
involves a focus on a single dimension of social exclusion. For example, the
relationships between health outcomes and poverty, labour market inclusion/exclusion,
access to services, various aspects of identity, social capital/social cohesion and place
have been extensively studied, as have the health experiences of homeless people,
refugees and people with mental health problems. Some of this is reported by other
knowledge networks. A recent systematic review of the relationship between mental
health and social exclusion identified 72 references, but inconsistencies in the way in
which social exclusion was defined and measured meant that the inferences to be made
from the papers were limited (Curran et al, 2007).
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most important limitation of all the available measures – including the more sophisticated
dedicated indicators of social exclusion – is that they are focused on providing ‘objective’
descriptions of states of exclusion, neglecting (with notable exceptions) the relational
nature of these ‘states’, the exclusionary processes generating them and the subjective
experience of the people most severely affected by these processes.
The complexity of the concept of social exclusion - its multi-faceted nature including both
objective and subjective elements – cannot be fully captured in numbers and indicators
and hence such numbers and indicators cannot be an adequate foundation for policy
and action. Rather, the nature and impact of exclusionary processes can only be
adequately ‘represented’ through both quantitative and qualitative data – through both
indicators and stories. Only by combining understandings of the nature and experience
of exclusionary processes obtained from both these sources will the effectiveness of
policy and action be maximised.
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In this part of the report we shift the focus to policy and action aimed at tackling
exclusionary processes. In Chapter 4 the relationship between actions to promote and
protect human rights and those focusing on reversing exclusionary processes is
introduced and a typology of the actions and policies appraised by the SEKN is
presented. This is then used to structure subsequent chapters which consider in turn:
policies and actions led by the State in all its forms (Chapter 5); initiatives at global,
regional and national levels to develop strategic approaches to the development and/or
co-ordination of policies/actions targeting social exclusion (Chapter 6); the role of
community action and non-governmental organisations (NGOs) (Chapter 7), and the role
of corporate social responsibility in the private ‘for profits’ sector (Chapter 8).
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The SEKN has not been centrally focused on human rights but a ‘rights’ perspective has
strongly influenced our work. In its Preamble, the Universal Declaration of Human
Rights points to the interdependence of civil, cultural, economic, political and social
rights, mirroring the dimensions of social exclusion highlighted in the SEKN model.
Indeed, the World Conference on Human Rights in 1993 argued that poverty and social
exclusion caused significant violations in human rights and called for urgent action to
address these, including action to ensure the participation of people experiencing
poverty in decision-making processes. More recently, a United Nations Development
Programme virtual round-table (UNDP, 2007) suggested that exclusion could be
translated as the UN non-discrimination clause, defined by the Human Rights
Commission to mean:
From this perspective, all policies and actions aiming to tackle dimensions of social
exclusion – whether or not they are explicitly described in this way - are concerned to a
greater or lesser extent with the protection and promotion of human rights, and this is no
less the case with the policies and actions appraised by the SEKN. However, before
presenting a synthesis of the results of these appraisals, two key issues need to be
clarified.
Firstly, a major challenge faced by the network was that globally there are relatively few
policies and actions explicitly described as addressing social exclusion or inclusion. In
this context, we sought to identify policies and actions focusing on one or more of the
four dimensions of the SEKN model and therefore, in theory at least, which had the
potential to tackle exclusionary processes. Secondly, it is important to reiterate that the
policies and actions appraised by the SEKN were not chosen because they were judged
a priori to represent ‘good practice’ in tackling exclusionary processes. Rather, the aim
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was to appraise a diversity of policies and action and identify the strengths and
weaknesses of different approaches with a view to making recommendations for action.
We also aimed to include approaches to policies and action which appeared to be
particularly common and provided scope for comparisons across countries and global
regions.
For the purpose of the appraisal synthesis presented here, policies and action have
been grouped on the basis of two criteria: the lead ‘actors’ involved and the ‘theory of
change’ underlying the policy/action. It is important to stress that whilst the typology
identifies ‘lead’ actors most of the policies and actions appraised by the SEKN involved
partnerships between more than one of these actors. So, for example, state initiatives to
extend access to health care may involve working with private insurance companies
and/or commercial health care providers.
The typology of actors and actions used to structure this part of the report is shown in
Figure 8 below.
Figure 8
Based Approach
Hybrid
Conditional transfers
and market based
approaches Action by NGOs
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As Figure 8 illustrates, five main ‘actors’ are involved in policies and actions judged by
the SEKN to be addressing dimensions of exclusionary processes: individuals and
households directly affected by exclusionary processes, the state in all its
manifestations, not-for-profit organisations (NGOs) and community actors, multi-lateral
agencies and pan-regional bodies such as the European Union, and private sector ‘for-
profit’ organisations.
The policies and actions appraised by the SEKN can be grouped into those ‘led’ by
nation states; those ‘led’ by NGOs, community groups and social movements and those
led by private sector organisations. The actions of multi-lateral agencies and donor
countries/agencies have only been appraised in so far as they are working in partnership
with nation States, NGOs or private corporations or are strongly influencing the action of
others. The fifth domain of action shown in the diagram is that of the individuals and
households most directly affected by exclusionary processes. In the absence of other
sources of support and/or when the support available does not provide for a decent
quality of life, people adversely affected by exclusionary processes will act in whatever
way they can to further their own interests. Whilst not formally appraised by the SEKN,
the creativity and resilience reflected in these ‘survival strategies’ is described in some of
the SEKN Background Papers.
The policies and/or actions which have been appraised can also be grouped according
to the ‘theory of change’ underpinning them; though these ‘theories’ are typically not
made explicit they can be derived from consideration of the nature, and where available
the formal aims, of policies/actions.
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In practice these different theories of change are combined in many country contexts,
producing hybrid policy initiatives. For example, not all conditional transfers are targeted
at particular low income groups (for example, the female secondary school stipend in
Bangladesh) and universal services can be conditional (for example, child benefits in
France).
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Private sector action: For the purpose of the SEKN work, private sector action has been
divided two types: service provision, such as insurance, health care or education –
discussed in this report in the context of state led policies and actions – and actions
broadly labelled corporate social responsibilities. The latter actions, which include the
activities of private corporations as employers and activities on a broader front, are
discussed in a separate chapter.
Multi-lateral agencies: These include global agencies such as the various UN agencies,
the World Bank, and pan-regional agencies such as the Union. As noted above the
action of these agencies have been appraised only in so far as they work with or
influence other actors, notably national governments. However, as many of the SEKN
appraisals highlight, the theories of change underpinning the work of some of these
agencies have had a profoundly negative impact on action aimed at tackling social
exclusion. This is perhaps most obvious in relation to the widespread influence of neo-
liberal theories and theories relating to the social management of risk strongly espoused
by the World Bank. These theories call for a reduction in the role of the state in welfare
provision, emphasis on targeting and conditionality rather than universal approaches to
meeting basic needs, and reliance on market-based approaches to addressing poverty
and inequality.
The chapters in this part of the report present summaries of SEKN appraisals of
policies/actions discussed in more detail in SEKN Background Papers. The chapters
consider in turn: state led policies and actions (Chapter 5); strategic initiatives by multi-
lateral agencies, pan-regional agencies and nation states aimed at policy development
and co-ordination (Chapter 6); community action and activities led by NGOs (chapter 7);
and the corporate social responsibility of the private sector (Chapter 8).
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The older ‘welfare’ systems of Northern Europe and other OECD countries have made
an important contribution to tackling exclusionary processes, promoting social cohesion
and population health improvements (See for example: Navarro et. al. 2006; Townsend,
2007). However, this type of state involvement has been under pressure over the past
few decades. In many countries state-owned services such as railways, energy (e.g.
electricity generation) and water have been sold to private providers and there has been
increasing pressure to limit access to free healthcare (discussed in more detail in the
report of the WHO Health Systems Knowledge Network). Free universal education
services and the state provision of housing are also under pressure. For example, in
England much public housing has been sold into private ownership (leaving the poorest
quality stock still in the hands of local authorities who are now required to divest
themselves of their responsibility for housing, transferring responsibility to civil society
organisations. In England fees have also been introduced for university education
alongside new forms of financial assistance involving both universal loans (with no or low
interest) and means tested benefits in an attempt to maintain access for those on lower
incomes. There is also an important debate about the continued relevance of the
assumption that the ‘nation state’ is the appropriate organising principle for welfare
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systems in the context of increasingly diverse populations and large scale movements of
people across national boundaries (Clarke 2004; Sassen, 2000; Williams, 1989).
The conclusions of Townsend’s review of OECD social security schemes are that:
• Historically, social security, albeit closely linked to labour market participation, was
accepted by all OECD member countries as a major path to modernisation and
sustainable growth and the principal means to reduce poverty. This path is being
actively pursued by new member states of the OECD and the EU.
• A mix of universal (i.e. social insurance and tax-financed group schemes) and
selective measures (i.e. aimed at particular groups tested) came to be developed.
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14
In a supplementary report methods of finding the global revenue to meet social security rights, and bring current
practices up-to-date are set out in some detail. The principal illustration is of a new application of the 1972 Tobin Tax,
a Currency Transfer Tax, to raise quickly a sum much larger than current levels of Overseas Aid and Debt Relief for a
UN Child Investment Fund to develop a system of child benefit in cash and kind in the poorest countries.
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From the perspective of social exclusion, and given, as we shall show, that current
policies focusing on poverty are emphasising targeting and conditionality rather than
universality, Townsend’s analysis of the cohesive potential of universal social insurance
schemes is particularly important. As he notes:
The democratic health reform movement which began in Brazil in 1976 included the
universal right to health enshrined in the new Constitution in 1990. Underpinned by the
principles of universalism, decentralization, comprehensive care and community
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participation, healthcare is delivered through the Unified Health System (SUS) to 75% of
Brazil’s population. All services at all levels of the health system are free of charge. In
1994 a Family Health Program (PSF) was created as part of SUS. Guided by the same
principles the PSF provides universal access to primary care as the gateway to a
publically funded healthcare system. Initially the PSF focused on poor areas but from
1998 onwards the approach was adopted by the Federal Government as a strategy for
transforming the existing national model of health assistance and financial incentives
were given to municipalities to encourage them to adopt the program. Under the PSF
Family Health Teams (ESF) were set up covering a population of 3-4000 people,
consisting of a general practitioner, a nurse, a nurse assistant and a ‘community agent’
selected from the local population. Some ESF’s also had Oral Health Teams (ESB). By
2006, 82 million people (46% of Brazil’s population) were covered by the Family Health
Program.
South Africa introduced free healthcare in 1994 within the first 100 days of the new
democratic government with the objective of improving access to essential health
services and removing financial barriers. Primary health care is free for everybody and
hospital care is free for children under 14 years, pregnant women, pensioners, persons
receiving social grants, disabled people and unemployed people. Diagnosis and
treatment for tuberculosis is also free, as are counselling and testing for HIV, services to
prevent mother-to-child transmission of HIV, cervical screening at primary health care
services and medico-legal support for survivors of sexual assault. However, health
services are not strictly universal in that access is means-tested and the policy excludes
people in formal employment earning more than $15 000 per annum unless they fit into
another eligible group (e.g. pregnant women). People who are in an eligible group but
have private medical insurance are also excluded.
South Africa, as is the case with other middle- and high-income countries, also has a
substantial private healthcare sector – a situation which illustrates the problems
generated for publically financed healthcare by parallel systems. There are significant
disparities between sectors in health spending, the availability of healthcare
professionals, access to and quality of care and coverage of population groups – with
the private sector doing much better than the public sector. In South Africa, it has been
argued that these disparities are one of the most serious impediments to an equitable
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health system (McIntyre et al, 2002; McIntyre and Gilson, 2000; Sanders and Chopra,
2006). The private sector undoubtedly faces challenges including, for example,
pressure of rising costs, criticisms of inequitable provision, unaffordability and
decreasing access to care. Generally, private healthcare services tend to be biased
towards urban areas and hospital-based treatment services, there is little interest in
prevention and little if any attention to essential services in support of meeting the
Millennium Development Goals (MDGs) (Rispel and Setswe, forthcoming). These and
other problems associated with private ‘for profit’ healthcare are discussed at length in
the final report of the WHO CSDOH Health Systems Knowledge Network.
Despite the dominance of neo-liberal thinking on a reduced role for the state in the
provision of healthcare, these services are still well funded in OECD countries and some
low- and middle-income countries are attempting to establish similar systems. It has
not been possible for the SEKN to undertake a comprehensive assessment of the impact
on population health, health inequalities and exclusionary processes of these state-led
initiatives to provide universal healthcare but there is some evidence of positive impacts
even at this early stage and lessons for others wishing to move in this direction,
summarised in Table 5 below. Common impacts across these policies include:
significant increases in the coverage of healthcare provision (both primary and specialist
care) and increased utilisation rates, particularly amongst women and children, and
increases in user satisfaction. There is also evidence of positive impacts on population
health from both Venezuela and Brazil, and in Brazil evidence of wider economic
multiplier effects with an increase in employment in the healthcare sector. In South
Africa the HIV and AIDS epidemic is presenting a major challenge for population health
improvements with increases reported in infant and child mortality and maternal mortality
remaining unchanged. However, it is arguable that the situation would be even worse
without the healthcare reforms.
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The strategy combines universal and targeted approaches. A key universal policy has
been the Child Benefit introduced in 1977 to replace the means-tested benefits in place
since the late 1940s. Child Benefit is paid to the ‘main carer’ of a child or young person
up to the age of 16 (or 18 for young people in full-time education or training). It is a
simple, effective and popular way of providing financial support for families, and
achieves near-universal coverage. It has been estimated that increasing the lower
weekly rate of Child Benefit currently paid for second and subsequent children
(UK£12.10) to that paid for the first child (UK£18.10) would lift a further 250,000 children
out of poverty - albeit at a cost of UK£1.6 billion (US$ 3.2 billion) (Harker 2006:53).
From 2009, pregnant women will also be able to claim Child Benefit from the 29th week
of pregnancy. In the meantime it was announced in 2007 that a one-off cash payment of
UK£120 would be given to all women in the 7th month of pregnancy, conditional upon
them receiving professional health advice on diet and on stopping drinking and smoking.
Other financial support for families is available through a complex mix of cash transfers
paid through the welfare and tax systems, most of which are means-tested and/or have
conditions attached. As in many other countries, conditionality is a core feature of the
labour market policies introduced in the UK since 1997, and getting parents (especially
lone parents) into work is a key strand of the child poverty strategy. Some of these
means-tested and conditional policies are described respectively in sections 5.2 and 5.3.
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Since 2003, Every Child Matters (ECM) has become the broad policy framework for
improving outcomes for children, young people and their families in England. This
framework emphasises service integration, prevention and early intervention, and cross-
government/department working. Engagement of children, young people and their
families in the decision-making and implementation process is a key policy objective. It
aims to achieve outcomes shared by 11 government departments, most notably in the
areas of health, safety, education and learning, health-related behaviours (e.g. smoking)
and economic activity. Universal support is made available to all children and their
parents, with more specialised targeted support to meet the needs of families and
communities facing additional difficulties. For example, there has been significant new
investment in the provision of subsidised pre-school care, and all three- and four-year-
olds have the right to 12½ hours of free care regardless of the employment status of
their parents. Overall there has been a substantial increase in expenditure on children’s
services, and by 2001-02, public spending per child had grown in real terms by almost
20% compared to 1996-07. Per capita expenditure was around UK£5,000 (US$10,000)
per child in 2001-02, with expenditure on poor children estimated to be about twice as
much as that on non-poor children; mechanisms to skew expenditure in favour of poorer
children and their families included means-tested benefits, rationing of some services,
needs-related provision and targeting of initiatives on areas of deprivation.
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other miscellaneous items, which were financed by households, will be covered by the
state or by other means. The impact of the policies on student registration and the
numbers of students completing their education will depend on the ability of households
to meet these additional expenses if they are not covered by an increase in government
support.
Research suggests that this social assistance programme is helping to reduce poverty,
contributing to social cohesion and having a positive impact on the economic
opportunities of households (IRIF 2006). It has been estimated that a 10% increase in
the take-up of old-age pensions reduces the poverty gap by 3.2%, while full take-up
reduces the poverty gap by 6.2% (Masango, 2004). In addition to providing income in
the short term, these social grants appear to promote second-order effects that have the
potential to move people out of poverty in the longer term. Households receiving social
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grants are more likely to send young children to school, provide better nutrition for
children, and look for work more intensively and successfully than workers in
comparable households that do not receive social grants (IRIF, 2006).
There are, however, constraints on this programme achieving its potential for poverty
reduction. Most importantly, although the number of beneficiaries of these grants has
risen rapidly since 1999, uptake remains low with huge estimates of unmet need
(Woolard, 2003). Additionally, devolved administration of the system to province level
was associated with a number of problems, including fraudulent grants, delays in
approving and paying grant applications, and difficulties in accessing payment, with
great inequity across provinces. Consequently, in 2004 the South African Social
Security Agency (SASSA) was established to implement and administer social grants.
Makiwane and Udjo have investigated allegations that the CSG has perverse
incentives, for example, encouraging women, especially teenagers, to have more
children (Makiwane and Udjo, 2007). However, the findings on this matter are
inconclusive and further work has been commissioned to investigate the relationship
between the CSG and teenage pregnancy.
In the UK, the Working Families Tax Credit (WFTC) was introduced in 1999 as part of
the government’s strategy to reduce child poverty. This provided support in the form of
a tax credit to parents working 16 hours or more a week and earning low incomes below
a threshold level. Up to 70% of childcare costs could also be paid by the State through
a childcare tax credit. This was replaced in 2003 by the Working Tax Credit (WTC)
available to all low-income adults working 16 hours or more, regardless of whether they
had dependent children and an additional means-tested Child Tax Credit (CTC) for
each child’s main carer. There have been serious problems with the uptake of these tax
credits. Estimates suggest that around a third of eligible families (600,000) failed to
claim WFTC and although more low- and moderate-income families are reached by
CTC than by the previous system, it was still estimated that around 18% of eligible
families did not claim in 2004-5 (HMRC, 2007). There have also been administrative
problems, including overpayment and error. Despite the problems, tax credits have
contributed to an increase in household incomes for the poorest fifth of the population of
around UK£3,000 per year in real terms between 1997 and 2004. Additionally, by
raising low incomes in absolute terms, fiscal and benefits policy (including but not
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restricted to tax credits 15) has been progressive, benefitting the poorest families most. In
2005-06, cash benefits made up 61% of gross income for the poorest fifth of
households and whilst the income before taxes and benefits of the top fifth of
households is estimated to be 16 times greater than that of the bottom fifth, the ratio
falls to four-to-one after taking account of taxes and benefits. In contrast, indirect taxes
are regressive, taking 11% of gross income from the top fifth and 27% of income from
the bottom fifth of households. Moreover, New Labour has not reversed the increases in
wage inequalities that occurred in the 18 years before they were elected; overall income
inequalities have remained largely unchanged and in 2005-06 the UK Gini coefficient
was the highest in Europe at 0.35.
15
Housing benefit and council tax benefit are other means-tested benefits estimated to have
lifted 800,000 children out of poverty.
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According to provincial government figures for 2007, 487,545 children under 6 years, 1.1
million children aged 7 to 14 years and more than 1.6 million parents are benefiting from
the Bana Pele programme. This includes 310,000 primary school children exempted
from school fees, 378,298 on the school nutrition programme, 40,000 receiving free
school uniforms and 66,000 transported to school. In terms of job creation, about 25
women's groups have been involved in the manufacturing of the school uniforms and
more women have secured employment as feeding scheme service providers. Whilst the
programme is close to reaching its target in terms of the number of children benefiting,
there have been problems with implementation and referrals across services are not yet
working well. A formal impact assessment of the programme has not been done and
there is no evidence as yet on the health and/or welfare impact (e.g. reduction in
vulnerability).
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living in informal settlements. 16 In this project, City Corporations work with NGOs which
set up health centres with funding from the Asian Development Bank, UNDP, DFID,
CIDA and EU. The poorest women and children living in these settlements are offered
subsidised good quality primary healthcare services and constitute 75% of all
beneficiaries. The ultra-poor receive services free. Coverage of primary care services
increased from 400,000 people in 2001 to 5 million in 2004. Users are reported to rate
the services as very good quality and as user-friendly. The NGOs initially rented
accommodation but now have all purchased facilities. The project has been facilitated by
the speed with which the NGOs have been able to adapt to the needs of the
communities they serve. The project has expanded to six City Corporations and five
municipalities and donors have promised continued support.
Sure Start local programmes (SSLPs) were established in 1999 as part of the English
government’s policies to reduce child poverty and social exclusion. These programmes
are geographically targeted being set up in the poorest areas of the country. They offer
integrated childcare and family support and aim to enhance early child development. All
children under the age of four and their families living in the SSLP area were eligible.
This had the advantage that SSLP services were universally available in the locality and
potentially therefore less stigmatising than interventions targeting individuals. SSLPs
have considerable local autonomy and do not have a prescribed curriculum of services.
Instead, each SSLP was given freedom to improve and create services in response to
local need. Children’s Centres are a later development aiming to extend Sure Start
services to all children in England.
Early results from a national evaluation of SSLPs (Melhuish et al, 2005) produced little
evidence that service use and/or usefulness had increased, or that families’ impressions
of their communities had improved. On the positive side, mothers of 9-month-old
children reported significantly less “home chaos” than controls, mothers of 3-year-olds in
SSLP areas also reported less negative parenting, and 3-year-old children of non-teen
parents exhibited fewer behaviour problems and greater social competence than those
in comparison communities. On the negative side, the evaluation also found some
evidence that carers and children from less disadvantaged households were benefiting
16
This section is drawn from: Rashid SF. (2007). Social Exclusion of Urban Populations that live in slums in Bangladesh, a
Background Paper for Social Exclusion Knowledge Network. ICDDR,B Working Paper. ICDDR,B: Dhaka, Bangladesh.
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more from SSLPs then those from more disadvantaged households, for example, young
mothers and workless households. There was no statistical difference in health
outcomes between SSLP and comparator areas but these would not be expected so
early in the intervention. Finally, there was considerable variation in performance
between programmes, with some evidence that programmes led by health agencies
became operational more quickly than those led by local government agencies and
generated more beneficial effects, but available published reports do not elaborate on
what these beneficial effects were.
Studies of the SRHI scheme all report that it increases the resources directed at poor
people who have higher health service utilization rates compared to people on low
incomes who are not eligible (Flórez et al., 2007). However, many critics point to
problems with equity in access to effective services, to the quality of services and to
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health outcomes. For example, the maternal mortality ratio increased between 1996 and
2003; although it then began to fall by 2005 it was still at the 1998 level of 68 deaths per
100 000 live births. A major problem is the difference between the two benefits plans:
poor people have a greater risk of ill-health but receive only 60% of the services received
by people on higher incomes in the contributory scheme and the services provided may
be of poor quality. Reflecting these differences, for example, poor women affiliated to
SRHI are not eligible for preventive mammography, so they present at hospitals with
later-stage breast cancer and have higher mortality than those in the contributory
scheme (Velázquez et al, 2007). Evidence also suggests that infant and maternal
mortality is higher amongst beneficiaries of the subsidized scheme compared to those
who have no insurance, and are covered by the previous model of open public hospitals
(Ramírez & Yepes, 2007) This is being interpreted by some groups as suggesting that
the per capita payment is encouraging providers in the subsidized scheme to put in
place administrative and geographical barriers to deter access and/or delaying referral to
secondary care, putting mothers and children at risk whilst the fee for service for the
uninsured is not having this perverse effect (Ramírez & Yepes, 2007).
In addition to access problems and possible differences in health outcomes between the
schemes there are other problems with Colombia’s subsidized health insurance scheme
(Grupo de Protección Social, 2007) including:
• The information system for targeting has major weaknesses including:
o Poor targeting e.g. 22.1% of eligible people have been excluded (i.e. 5.4
million people) and 26.7% of people whose income is too high have been
included (i.e. 7 million people).
o Failure to update: benefits continue to be paid to people who have died.
• The SRHI scheme is open to corruption and patronage at a local level involving
politicians and paramilitary and guerrilla groups.
• Public resources are being invested in the private financial sector more than in
health services
• There is no incentive for insurers to invest in prevention and health promotion.
• Social participation in health is reduced: service users are relegated to the role
of individual consumers of healthcare preventing the system from having wider
social cohesion benefits.
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The government has announced the introduction of universal insurance cover in 2009
but despite public debate about the inequalities in the service provided under different
schemes there is no intention to remove them at this stage.
Peru has introduced similar reforms in social protection systems to those implemented in
Colombia. The “Integral Health Insurance” for low-income people was introduced in 2001
and the Free Scholar Insurance, introduced in 1997, provides healthcare access to
children in low-income households provided they attend school – the application of the
principles of conditionality to subsidised insurance. However, unlike Colombia, these
schemes are financed in full from taxation and are managed by an autonomous public
body, the “Seguro Integral de Salud-SIS”. This public insurer has defined five different
benefits plans for beneficiaries of the Integrated Health Insurance scheme, depending of
age and patterns of demand: children less than 5 years old, children and adolescents,
pregnant women, adults, and older people. This means-tested program covers 15% of
the total population.
The SIS has increased the targeting of public resources to poor people (Portocarrero,
2005) and utilisation rates are higher amongst beneficiaries in comparison to non-
affiliated poor people. However, the scheme has many operational problems and
insufficient capacity to meet demand (Lenz & Alvarado, 2006; Petrera & Seinfeld, 2007).
Other problems which have been indentified include: delays in the flow of resources
between the SIS and public hospitals; too few service providers; limited accountability;
limited attention to the quality and effectiveness of services; inadequate targeting and
undue political pressure on decisions about eligibility.
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income families on condition that they register their children in school and attend a
specified proportion of lessons.
Today, conditional approaches dominate poverty reduction initiatives around the world.
In Latin America, CCT programmes include: Superémonos in Costa Rica; Atención en
Crisis and Mi Familia in Nicaragua; Red Solidaria in El Salvador; Tarjeta Solidaridad in
the Dominican Republic; PATH in Jamaica; Familias en Acción in Colombia; Juntos in
Perú; Bolsa Familia in Brazil; Red de Protección and Promoción Social in Paraguay;
Plan Jefes de Hogar Desocupados and Plan Familia de Inclusion Social in Argentina;
and Chile Solidario in Chile. In the UK, they include Educational Maintenance
Allowances, Lone Mothers Income Support and the New Deal programmes for selected
groups, aimed at getting people into paid employment. In Africa examples include the
GAPVU/INAS cash transfer programme in Mozambique and the productive safety net
programme in Ethiopia, and in South East Asia the Female Secondary School Stipend
Project (FSP) in Bangladesh. Many of these policies are led by the state in partnership
with private sector companies and/or non-governmental organisations. Some, including
micro-finance schemes are led by non-governmental organisations and are described in
the next chapter. In Europe and North America these programmes are generally paid for
by central government. In Latin America funds are provided by central governments with
support from the World Bank and the Inter-American Development Bank (IADB). In
other global regions funds are provided by other multilateral agencies, including for
example the Asian Development Bank, national governments in the richer nations (e.g.
DFID) other donor agencies and large NGOs.
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Familia, (PBF) appraised in SEKN Background Paper 12, is an example of this type of
CCT.
PBF is a very large scale national conditional cash transfer programme focused on low-
income families with dependent children, established in Brazil in 2003. It brought
together a number of previous conditional cash transfers to low-income families
established from the early 1990s in the newly democratic Brazil as part of a national
government strategy to eradicate poverty. Bolsa Família operates in all urban areas; the
stipend is means-tested and consists of cash payments for each pregnant or
breastfeeding woman and for each child aged 6 - 16 in households meeting the income
criteria, with an additional payment for the poorest households. The conditions to be
met by recipients include:
• School registration of children aged 6 - 15 who must attend at least 85% of
classes each month;
Penalties for not meeting conditions range from a warning through partial deductions to
full suspension of the stipend and are frequently imposed regardless of the reason for
non-compliance.
Families are registered at the municipal level but the decision regarding eligibility is
made at federal level. The Federal government provides funds for the programme to the
municipalities who are expected to provide the necessary health and education services
and monitor compliance with the conditions. Municipalities are also expected to provide
complementary services to increase the capacity of people living on low income to
improve their standard of living and quality of life including, for example, adult literacy
courses, training for work-related qualifications and facilities to help people obtain civil
documents such as birth certificates.
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Between 2003 – 2006 around US$ 6.1 billion were invested in Programa Bolsa Familia
and in January 2007 around 11 million families received a stipend. Local surveys have
explored people’s experience of the PBF and how they spend the extra money. A
majority of respondents - 85% - considered the programme good or excellent and 87%
reported that family life has been better or much better since receipt of the stipend. On
average the stipend is estimated to have increased household income by around 21%
and the extra money is being spent on food, school equipment, clothing and medication.
Overall, 86% of families say they are eating better or much better. Around two thirds of
families report an increase in the quantity of food consumed and 66% of children in the
households studied were eating 3 meals a day. The stipend is also contributing to the
empowerment of women by giving them control over resources and there is evidence
that adults in low-income households in receipt of the stipend (particularly men) are more
likely to seek paid employment than those in similar households without the stipend
Whilst economic inequalities are still very large in Brazil (with the richest 1% of the
population receiving the same share of national income as the poorest 50%) they have
been reducing. Buoyant labour markets and favourable economic conditions have
contributed to this reduction in inequalities but the development of more effective
systems of social protection has also played a part. For example, estimates suggest that
incomes from public transfers account for between 55% and 58% of the reduction in
poverty, the PBF making a significant contribution. For example, in 2005, 11.2%
(169,500) of the families receiving benefits from PBF moved out of poverty altogether
and 36.6% (1,891,937) were lifted above the extreme poverty line 17.
There is also evidence that PBF is having important multiplier effects in local economies,
particularly in the poorest regions. In municipalities in the Northeast Region, for example,
between 13% and 45% of the population are in receipt of PBF stipends, and resources
linked to the PBF are greater than local public income and all other federal transfers
combined. In addition to reducing the pressure on families to migrate out of these
17
Brasil. Ministério do Desenvolvimento Social e Combate à Fome. Catalogo de indicadores de monitoramento dos
programas do MDS. Brasília: MDS; SAGI, 2007).
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Notwithstanding these positive equity effects, it is important to stress that the absolute
level of resources transferred to the families covered is very low: the maximum PBF
stipend allowed to a family living on a monthly per capita income of US$30 or less,
regardless of the number of children in the household, would be US$70 a month - less
than half the minimum wage. There are also problems with the coverage of the PBF. It
has been estimated that 90% of the 15 million families registered for PBF met the
eligibility criteria, yet only 79% of these families are in receipt of a stipend. Each
municipality receives a maximum annual amount to spend and this is not necessarily
sufficient to cover all households who meet the eligibility criteria. Ultimately, receipt of
the benefits is dependent on the availability of resources at municipal level and there is
no mechanism to expand resources when they run out. The family income required for
eligibility is also extremely low (less than US$30 per capita per month). This inevitably
excludes many families living on very low incomes and around half of families defined as
‘indigent’ – with monthly family per capita income of less than US$41 or.less than a
quarter of the minimum wage – are not receiving the stipend. Evidence also suggests
that uptake amongst eligible families is lowest in those on the lowest incomes.
Conditional cash transfer programmes, particularly those on the scale of PBF, are also
complex and expensive to administer. Monitoring information is collected at municipal
level but assessed federally and available information suggests that around two thirds of
families are meeting the educational conditions and almost 100% are meeting the
health-related conditions but the coverage and quality of monitoring information is
problematic. For example, only a third of families subject to health-related conditions are
being monitored. Local research also suggests that some municipalities are failing to
provide the services families need to meet the conditions, and where they are available
services (particularly schools) are often of poor quality. When PBF was introduced it was
also the intention that municipalities would develop a range of complementary services
to support people living on low income to develop their capacities, including for example
adult training and education facilities. However, to date very few municipalities are
providing these wider complementary services.
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At the beginning of 2007 Argentina had around 1.5 million people in receipt of
conditional cash transfers through two national schemes: the Plan Jefas y Jefes de
Hogar Desocupados (PJJDH), and the Plan Familias por la Inclusión Social (PFIS). The
Plan Jefas y Jefes de Hogar Desocupados (PJJDH) was established in Argentina in
2002 in response to growing social unrest caused by the high levels of unemployment
and poverty resulting from the neoliberal reforms in the 1980’s and 1990s. It aimed to
establish the right to social inclusion for families initially through the award of
unconditional cash transfers of 150 Argentinean Pesos (US$ 47.68 at December 2007).
Eligible households included those: with dependent children or a disabled child of any
age where the household head is unemployed (male or female); those in which a woman
is pregnant; and those with unemployed young people or older people aged over 60 not
in receipt of other social benefits. In 2002 conditions to receipt of benefit were
introduced with beneficiaries having to choose to adhere to one of four conditions:
voluntary community work; formal education; take up formal work related training; or find
paid employment. These activities must last for at least 4 hours a day and failure to
comply results in loss of benefit.
There were some novel aspects to PJJHD. Instead of the usual complex eligibility
procedures, it involved a process of ‘self targeting’ whereby people made a simple
declaration to identify themselves as eligible. Administration of the plan also has an
element of civil society involvement. With the National Council of Administration,
Execution and Control (CONAEyC) involving representatives from the government
department, trade union movement, churches, and NGOs. Locally consultation councils
have been established to oversee the scheme locally involving representatives from
local government, trade unions, local businesses and social and religious organizations.
The plan has been criticized on a number fronts. The benefit is too low to cover basic
needs and does not take account of household size (CELS, 2003; 2004). The scheme
does not cover unemployed youth (a group at high risk of long term poverty) and there is
no formal procedure for beneficiaries to challenge decisions. The scheme has not been
formally evaluated and the local Consultation Councils have limited themselves to
bureaucratic and administrative tasks failing to consider the quality or impact of the plan.
However, there is evidence that 16% of the beneficiaries (340.000) shouldn’t be
receiving the benefit (Burion et.al, 2004; López Zadicoff, Paz, 2003) and in the five main
regions around 25% of the beneficiaries do not meet the conditions (Ministerio de
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Trabajo, 2003). The World Bank reported a reduction of the unemployment index of
2.5% (Galasso, Ravallion, 2003) but other data suggest that only 703 beneficiaries have
paid employment in the formal economy whilst 94% of those who are working are
involved in voluntary community work with no health or social protection (Ministerio de
Trabajo, 2002; CELS, 2003).
The scale of the PJJHD is without precedents in Argentina: reaching 16% of all
households in the country, and 40% in the poorest regions: 71% of beneficiaries are
women and 60% of these are living alone with children. More than half of beneficiaries
are aged under 35 (Ministerio de Trabajo, 2006).In 2003 the total PJJHD budget was
approximately A$ 3.000 million (US$ 954 million) with 20% provided by the Treasury and
the rest through a loan from the World Bank. However, between 2003 and 2007 the
number of PJJHD households in receipt of benefit has fallen from 2 million to 1 million.
The reasons for this decline include better availability of employment, mistakes in
registration and children reaching the upper age limit. However, the most important
factor has been the government’s decision to transfer families to a new Plan Familias por
la Inclusión Social (PFIS).
The PFIS, like PJJHD, is a conditional cash transfer involving payment of a regular cash
benefit to eligible households with children aged under 19 (with no age limit for disabled
children). However, it differs from PJJHD in that it aims to protect children rather than
being a wage substitute. Additionally, the stipend varies accordingly to the number of
children in a household (US$ 50 for one child, around US$ 60 for two children up to the
maximum of around US$ 100 for a family with six children) and the conditions are
different: immunization of children accordingly to the National Plan; regular attendance
at pre-natal clinics by pregnant women; and regular school attendance of children.
Compliance with conditions is checked twice yearly. The plan also aims to build the
capacity of civil society by giving technical and economic support to civil society
organizations to provide healthcare, childcare and educational services for children and
adults, to support local councils and to organize exchange visits. The number of families
receiving the stipend rose from 240,000 in 2005 to almost 400,000 in 2006 and the aim
was to reach 700,000 families by 2007. The money transferred to families increased
from US$ 71 million in 2003 to US$ 191 million in 2006 (Ministerio de Desarrollo Social
2006 y 2007). Although PFIS is at an early stage of development it has already been
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criticized for undue emphasis on large urban cities and restricted access for families in
rural areas or small municipalities.
The Female Secondary School Stipend Project (FSP) in Bangladesh 18 is another large-
scale CCT programme – as the name suggests it is targeted at girls of secondary school
age in rural areas but unlike the CCT progammes considered so far this is not means-
tested. It was initially introduced at a local level in 1977 by the Bangladesh Association
for Community Education but over time partnerships with the Bangladesh government
and international agencies enabled the programme to be scaled up with additional
funding from IDA/World Bank, the Asian Development Bank and the Norwegian
Government and by 1994 it was a national programme. The aims of the FSP have
evolved over time but the enduring objectives have been to increase female enrolment
and retention in secondary education, to delay marriage, reduce fertility and increase
female employment opportunities and earning potentials. The programme involves the
payment of secondary school tuition fees for girls up to class 10 living in rural areas and
a monthly stipend to their families paid regardless of household income. The conditions
applied to receipt of support reflect the dual concern of the programme with education
and marriage/fertility. The stipend is only paid if girls remain unmarried, attend
recognised institutions, maintain at least 75% attendance and secure marks of at least
45% in annual examinations. When the programme was scaled up nationally, nearly
twice as many girls as anticipated joined and by 2007 there were 2.3 million girls
enrolled.
There are many barriers excluding girls from education in Bangladesh, particularly at
secondary level, including the tradition of purdah, poverty, and the primacy of marriage
and childbirth. The extent to which the FSSP has been able to combat such barriers is
discussed in detailed in SEKN Background Paper 11, albeit with very little data. Despite
the lack of robust evidence there is general agreement that the programme has made an
important contribution to Bangladesh’s dramatic progress in achieving gender parity in
secondary education. In 1990 only 33% of enrolled secondary school students were
female: fifteen years later this proportion had increased to 52%. However, the FSP is
18
This section is drawn from: Schurmann A. (2007) Review of the Bangladesh Female Secondary School Stipend Project
Using a Social Exclusion Framework. Background paper for Social Exclusion Knowledge Network. ICDDR,B Working
Paper. ICDDR,B: Dhaka, Bangladesh. This is summarised in SEKN Background Paper 11.
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only one of a number of policies aimed at increasing school registration and retention
and the stipend only covers a small proportion of the full costs of secondary education.
Additionally, the programme makes insufficient provision for the multiple disadvantages
faced by low-income families, thereby disproportionately benefiting land-rich families
who can afford to put their children through primary school. The FSP also does little to
retain students after enrolment and absenteeism and drop-outs are common, primarily
due to lack of money, dislike of school and the need for children to work – reflecting
enduring financial barriers to education. FSP is also expensive, directing 6% of the total
public education budget and 14.5% of the secondary education budget away from those
girls most severely affected by exclusionary processes.
It has been argued that the programme would be more effective and sustainable if it
targeted the ultra-poor but this would be an unpopular move leading to loss of support
from influential sectors of the population. Increased enrolment has also put a huge
strain on the school system affecting the quality of education: learning achievements are
reported to be low and worse for girls than boys, teachers are under-qualified and in
short supply and infrastructure is poor, with a quarter of schools without toilets. The
secondary school system has also been criticised for failing to prepare students for
employment, focusing instead on entry to higher education.
As noted above, the FSP was part of a wider policy push to control fertility, to curb
unsustainable population growth. As married girls are excluded from the FSP, there is a
clear incentive for parents to delay girls’ marriages and a report by the World Bank in
2002 argued that the impact on the age at which girls marry had been significant and
immediate, reporting a fall between 1992-95 from 29% to 14% of girls aged 13 -15 years
marrying and from 72% to 64% of those aged 16 -19. These trends are, however, not
reflected in national data and there is some evidence that because the FSP results in
money coming into households linked to female children, it has changed parent’s
perception of the value of their daughters, but there is no direct evidence that the FSP
has had a significant impact on female empowerment or increased employment
opportunities for girls. Indeed, it has been argued (Raynor 2004) that community
support for the programme is dependent on it being seen as education to make women
better wives and mothers rather than as a route to female empowerment.
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Another type of CCT programme focuses on encouraging and supporting people into
paid employment. In these programmes the conditions for receipt of cash payments
include: willingness to access education and training, the active pursuit of employment
and attendance at work motivation interviews. In the UK, Educational Maintenance
Allowances (EMAs) and the New Deal for Young People (NDYP) are examples of these
types of CCTs. These policies are part of a wide-ranging policy initiative in the UK aimed
at promoting inclusion of young people by reducing the numbers not in education,
employment and training (NEET). They sit alongside major reforms to universal
education which aim to make provision more flexible, provide vocational advice and
reduce the status divide between vocational and academic qualifications. New anti-
discrimination legislation and other policies also aim to address the causes of under-
achievement of children and young people from some ethnic minority backgrounds.
The New Deal for Young People (NDYP) established in 1998 provides a package of
support intended to help young people find paid employment. Voluntary for the first six
months of unemployment, receipt of benefit thereafter is dependent upon a young
person accepting support including: a personal adviser, subsidised placements and
intensive individual support including counselling and training. Research funded by the
government found that NDYP has had a significant impact on movement out of
unemployment, but the primary impact seems to be on movement into education and
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training rather than paid employment. By 2006 just over a million young people had left
NDYP with 47% moving into unsubsidised employment. However, the proportion of
these young people finding sustained employment has been falling steadily since 1998
and the number of young people aged 16 -18 not in education, employment or training
increased slightly from 10% in 2004 to 10.3% in 2006. There is also evidence suggesting
that NDYP has driven some young people (unwilling to accept the support package) off
the unemployment register and may leave some in severe financial hardship through the
application of sanctions because of non-compliance. Around 13,000 young people are
sanctioned each year primarily for failing to attend work-related interviews or for
misconduct.
Conditional programmes aiming to get people into paid work are also a key strand of the
UK’s child poverty strategy. The rationale for the New Deal for Lone Parents (NDLP) is
that children of lone parents are almost twice as likely to be poor than those living in a
couple household, making up 40% of all children in poverty. The government has set a
target for 70% of lone parents to be in employment by 2010. Participation in NDLP
involves intensive support from a personal adviser aiming to build the recipient’s
confidence and provide practical help with job search techniques, applications and
finding childcare. The NDLP is voluntary, but most cash benefits for low-income parents
are either means-tested and/or conditional, with sanctions for non-participation. Lone
parent income support, for example is a means-tested benefit paid to unemployed lone
parents of dependent children, provided that they agree to regular work-focused
interviews at local job centres. The overall impact of these policies is modest but
positive: the employment rate amongst lone parents increased from 46% in 1997 to
56.5% in 2006 and nearly half a million lone parents had been helped into employment
by the NDLP. Freud (2007:44) argues that the NDLP has more than paid for itself in
fiscal terms but it is also likely that the buoyant economy in the UK has been a major
contributing factor. There have also been a number of criticisms of these policies in the
UK 19 notably:
19
For more detail see SEKN Background Paper 8.
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• Too much emphasis on supply-side issues, with little attention to job creation;
• Neglect of households with two parents relying on one wage earner;
• Failure to address inequalities between paid workers and the quality of paid work;
and ignoring unpaid work, in particular women’s household and childcare labour;
• The continued problem of low wages with nearly half of poor children in
households with at least one adult working despite the introduction of the national
minimum wage in 1999 (UK£5.52 in 2007);
• Tensions between a policy emphasis on labour market participation and policies
aiming to improve parenting.
Other CCT programmes, such as those in Mozambique, Ethiopia and Ghana, involve the
transfer of cash payments in exchange for participation in public work programmes
which focus on sustainable development: for example, soil and water conservation
projects. The Ethiopian programme also involves extensive community participation and
is discussed in more detail in Chapter 6 on Civil Society action.
Table 6: Benefits and Limitations of Conditional Cash Transfer Programmes
Positive results and impacts Problems, limitations and criticisms
• Reduction of poverty and increase of • Low coverage and stigma.
consumption, including nutritious food. • Limited attention to increasing access
• Increase in school registration and to and quality of services.
attendance. • Limited attention to outcomes of
• Increased uptake of preventive services services.
including child development monitoring, • Primary focus on economic
vaccination, prenatal/antenatal care. disadvantage and human capital
• Improved education and health outcomes development with limited attention to
e.g. decreased incidence of diarrhoeal socio-cultural exclusionary processes.
disease. • Limited intervention in quality or
• Reduced child labour. availability of employment.
• Increase in health-related knowledge and • Possible perverse incentives e.g.
healthy behaviour. increase in teenage pregnancies or
• Empowerment of women & communities. poor nutritional status of children in
• Reduced household asset depletion: less order to maintain the cash transfers.
likely to sell food in an emergency e.g. to • Greater burden for women.
pay medical fees; avoiding selling assets • Administration problems: inefficiencies
to buy food. due to complex system, high
• Increased accumulation of assets: transaction costs and high risk of
resources used for productive investment corruption.
e.g. education, livestock. • Potential negative impact on social
cohesion.
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The evidence reviewed above and elsewhere (see, for example, Lagarde et al, 2007)
suggests that conditional transfer programmes are associated with a range of positive
outcomes in the short to medium term including modest but important health status
outcomes. The most common benefits reported are listed in Table 6 above.However,
there are also important disadvantages associated with these programmes and
questions remain regarding their cost-effectiveness and the appropriateness of such
programmes in low-income settings, with more limited capacity in health and educational
systems.
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positive impact on school attendance when pills were given away but the introduction of
a small payment led to an 80% decline in their use. Similarly, Nahlen and colleagues
(2003) found that if households in Western Kenya had been given cash instead of
insecticide-treated bed-nets they would have spent the money on food and clothing with
bed-nets being a ‘distant priority’. One implication of this research is that ensuring that
household incomes are sufficient to meet basic needs should be a priority for policies
aimed at population health improvement. There is some evidence that conditionality (as
opposed to extra resources) is not required to support or promote responsible parenting.
For example, evaluation of unconditional cash transfers aimed at children (e.g. the CSG
in South Africa and Child Benefit in the UK) found that linking conditions associated with
child health and/or education to qualify for receipt of these benefits had limited additional
value, if any, as parents already spend extra resources on food, clothing and school
fees. Evidence from Brazil and South Africa also suggests that receipt of child benefits
has the added benefit of incentivising parents to seek paid employment.
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6.1 Introduction
This chapter considers two types of strategic initiatives. The first involves initiatives by
multilateral and pan-regional bodies aiming to promote new directions for policies and
actions with the potential to reverse exclusionary processes. The second involves
initiatives by national governments or state agencies within countries aiming to promote
better co-ordination and integration of existing policies and services, or reform of
services to better met the needs of groups most severely affected by exclusionary
processes. A comprehensive review - both in terms of locating the full range of strategic
initiatives in existence at international, national and local levels and appraising the
impact of individual initiatives – was beyond the resources available to the SEKN.
Rather, the SEKN selected a small number of initiatives at different levels (global,
regional, country and intra-country), describing the form they take and exploring their
potential contribution to action to address exclusionary processes. The examples
discussed below include at global/regional level: the Economic Commission for
Development of Latin America and Caribbean (ECALC); the International Labour
Organisation’s (ILO) Global Campaign for Social Security and Coverage for All; the
UNDP Poverty Strategies Initiative; the Framework for unified UN action and the
European Union’s Social Protection and Social Inclusion Strategy. At country level the
initiatives appraised include the social exclusion policy initiative in the UK, the Social
Inclusion Initiative in the state of South Australia, the Nigerian National Poverty
Alleviation Programme and Ghana’s National Social Protection Strategy,
6.2 Global and regional Initiatives for policy development and co-ordination
CEPAL/ECLAC: Contract for Social Cohesion
The Economic Commission for Latin America and the Caribbean (CEPAL/ECLAC) has
developed a proposal for addressing social exclusion and poverty which centres on a
new collective and political ‘Social Cohesion Contract’. CEPAL/ECLAC defines social
cohesion as “the dialectic relationship between the established mechanisms of social
inclusion or exclusion, and the responses, the perceptions and the disposition of the
people about the way in which these mechanisms work”. (CEPAL, 2007: 136; Sojo y
Uthoff, 2007). The aim of the CEPAL/ECLAC Social Cohesion Contract is to reduce
inequality in societies and enhance people’s sense of belonging. In order to build this
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The central elements of the Social Cohesion Contract proposed by CEPAL/ECLAC are:
“Labour flexi-security”: i.e. “to move labour protection from the employment to the
person” 20;
Education for increasing capabilities, including promoting values of multiculturalism
and democracy;
Financial strategies that promote social solidarity through universal social protection
systems;
Progressive structure of taxation;
Local multi-sectoral programs targeting disadvantaged groups.
All these strategies would be implemented within a framework recognising the respective
rights and duties of states, civil society, markets and individuals.
20
This concept is also under consideration in the European Union where is has been criticised by civil society
organisations as resulting in or contributing to the privatisation of welfare and a reduction of the role of the state in social
protection.
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for young people and women, the promotion of “social dialogue” and trade unions, and
social protection for all as workers in the context of globalization. The ILO approach
rejects the use of public resources to fund conditional cash transfers to increase
consumption, favouring instead the transfer of such resources to informal productive
units to support their transition to modernity through higher productivity and better
income for their workers (Levaggi, 2006:81-82).
The UNDP Poverty Strategies Initiative and the Framework for unified UN Action
In response to a commitment made at the 1995 World Social Development Summit
(WSDS) the United Nations Development Programme (UNDP) launched the Poverty
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Strategies Initiative (PSI). With US$20million from multiple funders this programme
aimed to assist countries in analysing and raising public awareness of the extent,
distribution and causes of poverty, creating political space for debate on national
priorities and formulating national policies and strategies to fight poverty. In 2000 an
evaluation of the impact of the programme in 18 countries was carried out by UNDP
(Grinspun, 2001). From a social exclusion perspective key findings of this evaluation
were that:
• Most measures of poverty neglect relational aspects e.g. between poor and non-
poor, powerful and powerless – measurement needs to be more dynamic.
• The agency and resilience of poor people is severely limited by structural constraints;
household coping strategies disproportionately affect women and can exacerbate
poverty and disadvantage by reducing long term asset formation.
• Social spending as a proportion of discretionary spending was higher than had been
thought but the proportion of public expenditure on basic social services was well
below the 20% agreed at the WSDS, partly due to debt repayment but also because
significant funds are diverted to defence expenditure.
• The fight against poverty is a deeply political issue concerned with disparities in the
distribution of wealth, power and opportunities – UN agencies may be best placed to
act as impartial advisers in convening national debates on poverty.
• National institutions play a decisive role in translating knowledge into policy. The
establishment of official Working Groups or National Commissions with a poverty
reduction mandate was a significant spin-off of the PSI programme in many countries
and donor agencies need to co-ordinate their efforts and make long-term
investments in establishing and supporting these institutions.
• Bolder action for capacity development is required to strengthen the ability of local
actors to identify problems in need of action, to commission work on the nature of
problems, interpret the results and use them for policy purposes.
Overall the research pointed to three critical factors required for action to nurture policy
change and encourage public commitment on poverty reduction:
• The right institutional actor – within or out-with government – with sufficient
credibility and stature to become the standard bearer of policy reform.
• The ability to broker processes ensuring the sustainability of policy reform
beyond the short-term.
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Poverty reduction remains one of the four interrelated development areas structuring the
work of the UNDP, but along with other UN agencies UNDP is currently undergoing a
process of reform which has the potential to significantly improve capacity to address the
complex dynamics characterising exclusionary processes. The Framework of Unified UN
Action seeks to bring together the work of disparate UN agencies at country level with
the aim of reducing duplication and increasing the synergies across agencies and
donors. Pilot work in eight countries is currently testing a model in which UN agencies
operate through a single ‘resident co-ordinator’ providing support for the development
and implementation of a comprehensive National Develop Plan aimed at achieving the
Millennium Development Goals.
The European Union’s strategy for social protection and social inclusion
Between 1974 and 1994 the EU member states implemented three major anti-poverty
programmes. As these programmes progressed the concept of social exclusion became
more established and between 1994 and 1999 the EU implemented an action programme
to combat exclusion and foster solidarity (Progress). Following this, at the 2000 Lisbon
Summit, European Council Heads of State formulated a strategy to combat social
exclusion in the EU and make a decisive impact on the eradication of poverty by 2010.
The strategy underlined the need to improve the understanding of social exclusion and to
organise policy co-operation across member states so that knowledge of how to address
social exclusion could be shared. Co-operation was to be based on an ‘Open Method of
Co-ordination (OMC) consisting of the following elements (Stubbs and Zrinscak 2005):
• All member states would adopt common objectives in the fight against poverty and
social exclusion and each state to produce a bi-annual National Action Plan on
Social Inclusion (NAPs/incl) providing data on poverty and social exclusion,
describing and assessing the impact of policies and setting out future action plans.
• Common social inclusion indicators - Laeken indicators – would be used (see
Section 3.3.2 page 61).
• New member states would produce mandatory Joint Inclusion Memoranda outlining
their country situation and political priorities on poverty and social exclusion prior to
full membership.
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• The EU council would produce a Joint Report on Social Inclusion as the formal
response to bi-annual NAPs/incl submitted by member States. From 2005 this
became the annual Joint Report on Social Protection and Social Inclusion.
• Country reports and the EU Council’s annual Joint Reports are intended to contribute
to shared learning on policy and practice to promote social inclusion across the EU.
There are widespread concerns that there has been a loss of momentum around poverty
and social exclusion in the EU since the 2000 Lisbon commitment, and official figures
suggest around 78 million people are at risk of poverty in the EU (EARN, 2007). In recent
research in nine Members States, for example, 50% of respondents felt that poverty and
social exclusion were still low on government agendas (O’Kelly & Litewska, 2006).
Notwithstanding these important concerns, it is clear that the EU social inclusion policy
initiative and the National Action Plans initiated by Member States can provide useful
learning about effective action to address exclusionary processes.
Country action plans are very diverse, reflecting in part different political priorities and
differences in policy dynamics. The Irish National Action Plan 2007-2016
(www.socialinclusion.ie.) is structured around a life cycle framework identifying 12 high
level goals in relation to children (with goals focusing on education and income support);
people of working age (with goals focusing on employment, participation and income
support); older people (with goals focusing on community care and income support),
people with disabilities (with goals focusing on employment and participation) and
communities (with goals focusing on provision of housing, primary healthcare and the
integration of new migrants). In France, in contrast and reflecting its welfare history,
action is focused strongly on social protection and the labour market, and in the UK
significant differences have emerged in the approaches adopted by the devolved
administrations of England, Scotland, Wales and Northern Ireland. There are also varied
policy initiatives in EU member states to foster inclusion of the Roma peoples. Such
diversity in approaches provides a rich basis for comparative analysis and, although Kelly
and Litewska (2006) argue that little formal evaluation of country action plans had been
undertaken, there is a formal audit process in place in all Member States. Resource
constraints have meant that the SEKN has restricted its detailed appraisals to activities
underway in the UK/England but SEKN Briefing Paper 9 provides brief descriptions of
plans and activities from a wider group of EU countries which could be appraised in the
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future.
The SEU policies reflect theories of change at the heart of the UK Government’s reform
agenda, including building a new social contract between government and the people in
which rights are accompanied by responsibilities, and full membership of society is
conditional upon the fulfilment of responsibilities; focusing on labour market inclusion as
the primary means to achieve social integration; emphasising preventive activities with
early interventions targeted at ‘critical transition’ points in life as a means of breaking
cycles of deprivation; and ‘joined up working’ to address complex, multi-dimensional
problems.
The work of the SEU raised the profile of social exclusion nationally and contributed to
the development of better relationships across government departments at a national
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level and between the government and the voluntary sector. This success was due in
part to its close association with the Prime Minister (which gave the work a high political
profile), the status of SEU reports as Government policy, links to influential Treasury-led
Spending Reviews and high level outcome targets set for government departments by
the treasury (Public Service Agreements), and its emphasis on policy delivery
mechanisms, principally new approaches to support joint work across government
departments.
There are, however, areas of concern. Arguably the ‘reach’ of the social exclusion policy
initiative has been more limited at local level than nationally. As reported in SEKN
Background Paper 8, although local policy-makers and practitioners are aware of the
social exclusion discourse, its impact on the substantive work being done has been
marginal with traditional ways of understanding policy problems - for example, problems
of multiple disadvantage - being ‘rebadged’ as problems of social exclusion. More
generally, there are concerns about the narrowing focus of the social exclusion agenda
over time, with its current emphasis on people described as ‘entrenched excluded’,
tapping into an enduring preoccupation in England with the notion of the ‘undeserving’
poor. As the population groups targeted become more narrowly defined the initiative
has less potential to contribute to social cohesion at a societal level, is less concerned
with the wider social inequalities which generate extreme states of exclusion, and runs a
greater risk of stigmatising that groups that are targeted.
There are also questions about the effectiveness of the policies implemented in the UK
since 1997, aimed at addressing social exclusion. For example, in their independent
review of the UK’s National Action Plan for Social Inclusion for 2003-2005, Bradshaw
and Bennett (2004) point out that although most key indicators of poverty and social
exclusion had moved in the right direction, much of this was to do with the performance
of the UK economy - increased employment and, to a lesser extent, tax and benefit
policies. They also expressed concerns about the degree to which poverty and social
exclusion policy was being mainstreamed across government departments and the
devolved administrations, and pointed to slow progress on relative poverty and the need
for policies which are more redistributive in impact.
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The SII has raised the profile of social inclusion in the State of South Australia and has
had some impact on people’s lives, but there is a view that alongside focussing on ‘those
who are socially excluded’ the SII should widen its focus to encourage broader cultural
change to address the beliefs, attitudes and actions of ‘those who are doing the
excluding’. Additionally, the traditional silo approach of individual agencies has probably
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been the major barrier to more joined-up ways of working. Evaluations have shown that
the SII has been a catalyst for an increase in partnership work but there is a perceived
need for greater capacity among public servants at all levels, and among service
providers and the community, to better understand social inclusion and the needs of
disadvantaged individuals and groups, and to strengthen the ability to work in
partnership. There are also questions about the continuity of the SII, if and when a
change of government occurs. Mainstreaming SII initiatives into the ongoing work of
other agencies and departments would contribute to sustainability but the SII has found
that other agencies often have difficulty in taking over responsibility for initiatives they
see as unfunded ‘non-core’ business. Incorporating targets relevant to social inclusion
more widely into South Australia’s Strategic Plan will also contribute to sustainability.
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also co-ordination committees in all 36 Nigerian states and monitoring committees have
been established in all 774 local government areas.
NAPEP is funded through tax revenue and additional resources from the private sector
and donor agencies such as the World Bank, the United Nations Development
Programme, the European Union, the UK Department for International Development, the
Japanese International Co-operation Agency, and German Technical Assistance. A
Poverty Eradication Fund (PEF), administered by the National Poverty Eradication
Council, funds special projects alongside the mainstream poverty alleviation
programmes funded by participating ministries. The NAPEP programme therefore
consists of policies and programmes within government ministries and special
intervention projects. Since January 2001, NAPEP interventions projects have included:
• Youth empowerment scheme: around 700,000 young people trained in practical
trades between 2001/5, paying N3,000 monthly to trainees and N3,500 to
trainers.
• The Mandatory Attachment Programme: 40,000 unemployed graduates found
training placements with a monthly stipend of N10,000.
• Direct Credit Delivery: loans to potential entrepreneurs and farmers to support
productive ventures to fight poverty including:
o Farmers Empowerment: the pilot involves 7,200 farmers in 12 states.
o Micro-Credit Schemes: by December 2005, over N450 million had been
released through 54 groups/Micro Finance Institutions (MFIs).
o The Promise-Keeper Programme: a collaboration with faith-based
organisations to provide interest-free loans for income-generating
economic ventures.
o The Multi-Partner Matching Funds Scheme: seeks to enlarge the funds
available for loans at optimal interest rates.
• The KEKE NAPEP project: now in its second phase involves purchase of 4,000
diesel Piaggio three-wheeler automobiles (KEKEs) for commercial transportation
in state capitals and viable urban centres.
• Youth information Centres to be established nationwide by NGOs
• Community Skills Development Centres: so far 47 established in 13 states in
collaboration with UNDP.
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• Establishing special training units in VVF Centres: under this scheme, NAPEP
purchased and delivered equipment and tools to the 10 VVF centres nationwide.
NAPEP also established a Special Micro Credit Scheme for all trainees.
There has been no formal evaluation of the impact of the NAPEP as a mechanism for
delivering greater integration across government departments; nor is there extensive
evaluation of individual programmes and/or projects included in NAPEP. However,
commentators have noted a number of problems with NAPEP activities including:
• Little if any impact on the wellbeing of the poor because they fail to address basic
structural inequalities in Nigerian society.
• Inadequate community participation.
• Unequal awareness of the programme with much greater awareness amongst
the educated elite than people who have literacy problems.
Additionally, research suggests that the Nigerian Government’s wider economic reform
programme has undermined attempts to reduce poverty and that the incidence of
poverty is rising despite the NAPEP initiative (Ezelola, 2005).
The NSPS includes the new Livelihood Empowerment Against Poverty Scheme
(LEAPS) developed on the basis of an extensive review of the international literature,
alongside existing social protection programmes including a supplementary feeding
programme, micro-finance, education capitation grants and skills training for young
people. Beneficiaries will be supported by LEAPS for two years and then re-directed to
other existing programmes and services. For LEAPS to fulfil its aims the NSPS has to
strengthen these other programmes and services. A range of implementation challenges
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facing LEAPS has been identified including the need to build the capacity of the
ministries responsible for implementing LEAPS, identifying skilled personnel (particularly
with IT skills), the lack of visibility and public support for the strategy because of the
stigma attaching to poverty, overlapping roles of institutions involved and inadequate
human, financial and logistics for effective delivery of services. Independent consultants
are to be commissioned to provide and support systems for implementation, monitoring
and evaluation.
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exclusion in small population groups rather than seeking to impact on the wider
societal processes generating these states. There is little evidence that mainstream
working has changed significantly as a result of these initiatives or that public
understanding of social exclusion and/or inequalities has changed. There is also a
tendency for action to be funded as discrete short term projects rather than aiming to
change the existing provision to better meet the needs of all sections of a population.
A number of generic lessons can be gleaned from international and national
initiatives aiming to support better co-ordination and integration of policies and
actions with potential to reverse exclusionary processes. In general these initiatives
will work more effectively if the following conditions are in place:
o Systems for measuring and monitoring which combine objective indicators
with experiential/subjective understandings and aim to capture the dynamics
of exclusionary processes, not just describe changes in states of exclusion.
o An explicit recognition that action to address exclusionary processes in
general and poverty in particular are political and therefore require formal
mechanisms to manage these political processes. International agencies can
be effective arbitrators at national level in some contexts.
o Strong and senior political commitment and leadership.
o Institutions established to take the initiative forward which are independent of
the state, have credibility as knowledge brokers/translators, have the power
to make decisions and can hold others accountable for acting individually
and/or in partnership to deliver change. Examples include a Standing
National Commission, an Independent Board or a ‘champion’;
o Key success factors including:
Institutional actors which have credibility and stature to act as
champions for the policies/actions involved.
A brokering process which ensures sustainability of the initiatives in
the longer term by integrating changes into mainstream policy-making
processes and service delivery systems.
Institutional reforms which move the social exclusion and poverty
discourse beyond narrow political agendas making them non-partisan.
o Resources and time dedicated to capacity-building – in terms of the technical
skills and competencies required for problem definition, knowledge
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Whatever the socio-political context, the primary focus of attention in these debates is on
the potential of communities, variously defined as a force to mobilize demand for
transparency and accountability in public and private sector governance. It is also
argued that if the target groups of policies are involved in policy decision-making and
implementation, provision will be more acceptable, more accessible and hence more
effective and positive outcomes will be more sustainable. It can thus be argued that the
participation and/or empowerment of the people targeted by policies and actions aiming
to address exclusionary processes is becoming the silver bullet of the 21st century. But
,as was the case with the pharmaceutical ‘revolutions’ of the 19th and 20th centuries, the
potential benefits of this new ‘silver bullet’ will depend on the nature of the community
actions involved as well as on the context within which these actions take place.
The term ‘community’ is problematic as is the related term ‘civil society’. As commonly
used, ‘civil society’ refers to all sections of society which are not part of the state; hence
it includes the private, voluntary and ‘not for profit’ sectors as well as lay communities. It
is therefore too broad and amorphous a term to be useful to the work of the SEKN. The
word ‘community’ is no less problematic: it can be used to refer back to an apparently
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golden age when social relationships between people were stronger, and reciprocity and
exchange were common, although there is little robust evidence that such a golden age
ever existed. More formally, the word refers to a group of people who share something
in common: this might be living in the same neighbourhood (communities of place) or a
characteristic such as being consumers of a service, having a particular medical
condition or sharing a common ethnic identity (communities of interest). It is this latter
understanding of the word community which has informed the work of the SEKN.
For the purposes of the work of the SEKN, three types of community action have been
identified:(i) large scale social movements typically aiming for political change and social
transformation; (ii) policies and actions, which may be sponsored by the State, NGOs or
others, that seek to promote community involvement in decision making and/or
community empowerment, and (iii) action by formal non-governmental organisations
(NGOs) to address exclusionary processes such as delivering services. Whilst the focus
of this chapter is on the potential for social movements, community action and
involvement to contribute to greater equality and social cohesion, the SEKN also
recognises that social movements and community actions, such as those characterised
by xenophobia, are strongly exclusionary and appropriate state regulation of civil society
action in all its forms is important.
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1990’s the social movement “piqueteros” lead to major welfare reforms including to the
new conditional cash transfer programmes introduced to increase the living standards of
poor households in the 2000’s.
Latin American social movements are involved in actions addressing all four dimensions
of exclusionary processes highlighted in the SEKN model. Action by feminist
movements has revealed the relationship between gender segregation, unequal pay and
unpaid domestic work. They have also highlighted the differential impact on women of
the economic crisis (Juliano, 2001; Jaggar, 2002). Latin American feminist movements
are also promoting a new development model aimed at promoting greater gender
equality (Caicedo, 2007). The Movimento dos Trabalhadores Rurais sem Terra (MST) in
Brazil is arguing for action more radical than the programmes based on subsidies for the
poor, advocating instead structural rural reform underpinned by a new economic
development model centred on an internal market (Coletti, 2004; Sampaio, 2007). Urban
unemployed people in Argentina allied their movement to traditional trade unions and
adopted a range of actions in pursuit of better working conditions, including road blocks,
domestic exchange and the occupation of enterprises by unemployed people called
empresas recuperadas (Iñigo y Cortarelo, 2004; Rodríguez, 2004).
In the case of Latin American indigenous movements, the central claim is for recognition
of their culture, autonomy and collective ownership of their ancient lands. A well-
established effective movement is the Zapatistas in Chiapas, Mexico. This movement
has established its own systems to provide food, housing, education and health
services, with traditional health providers complementing occidental medicine (Álvarez
Gándara, 2004). The Zapatista health services have delivered important health
outcomes sometimes in very short timescales, including a sharp decline in maternal
mortality (Villarreal, 2007; Joel, 2006). The indigenous communities in the north of
Guatemala have been developing similar services including healthcare provision
combining traditional and occidental medicines, with very good results (Albizu et al:
2005).
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better terms and conditions at work. Today social movements still focus on labour
conditions but the type of action has changed, including consumer boycotts and
campaigns to pressure industry and government into taking action on abuses of
employment practices in both developed and developing countries. Additionally neo-
liberal policies have undermined the labour movement in some countries whilst at the
same time, associated with globalisation, new forms of community organisations and
alliances are developing, including informal worker alliances in developing countries and
the “fair-wear” garment workers and anti-child labour campaigns in Europe, the USA,
Latin America, and Australia. In Norway a broad alliance of unions and community
groups has formed For velferdsstaten (For the Welfare State) to campaign against
market liberalism, and privatisation and in favour of social welfare and public services.
social movements are not spontaneous grassroots uprisings of the poor, as they
are sometimes romantically imagined, but are dependent to a large extent on a
sufficient base of material and human resources, solidarity networks and often
the external interventions of prominent personalities operating from within well-
resourced institutions (Ballard et al, 2005: 627).
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Formal civil society organisations can therefore be pivotal resources supporting the
emergence and sustainability of wider social movements.
The National Health System (SUS) in Brazil has social participation as a constitutional
principle, which is implemented through a system of health councils at national, state
and local level and health conferences held at each level every four years where the
main goals for health policies are established. The Primary Care Program – Programa
Saúde da Família (PSF) – as a part of SUS also promotes social participation through
local health councils. Fifty per cent of the membership of health council are users of
health services and 50% are representatives of health professional groups and service
managers. As in Venezuela, the Brazilian health councils at all levels are deliberative. An
ambitious attempt at community participation research, however, conducted in cities with
over 100.000 inhabitants where PSF was implemented, suggests that the system is not
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operating well. On average, 96% of the local communities did not know that an
assessment of health needs in a locality was supposed to be done with community
participation. Only a minority of residents (22% to 39%) knew where to go if they had a
complaint about health services, few people knew about the existence of the health
councils (8% to 26%) and the proportion of people participating in their Local Health
Council ranged from 0% to 26%. Similarly, only around a quarter (28%) of health
professionals surveyed knew about the existence of the Local Health Councils.
The 1998-2003 5-year plan also experimented with community ownership of health
facilities. The community was expected to donate the land, and construction costs were
shared between the local community and central government. However, membership of
the community groups was biased toward the local elite and relatives of the chairperson.
Leadership was poor and in the absence of defined structures, unequal relationships
were reproduced between rich and poor, and men and women, and little value was given
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to the voices of those with low status. The government was also unwilling to mobilize
resources and by 2001 all the clinics had fallen into disuse.
The review found a large volume of good quality research on the factors which enable
and/or constrain effective community participation in decision-making in the UK context.
The barriers identified include misuse of power by professionals who control both the
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agenda for participation and who is to be involved, a lack of appropriate skills and
knowledge on the part of professionals, practices of engagement which exclude people,
(including for example, the style and timing of meetings and a failure to accommodate
cultural diversity and accessibility issues), high transaction costs for lay participants (in
terms, for example, of the time commitment required and travel costs), and a range of
cultural and attitudinal constraints including negative stereotyping of disadvantaged
communities by professionals and local politicians. Research suggests that communities
may actively resist participating in decision-making, particularly when their past
experience of participation is that it does not influence the decisions that are made. This
has particular salience in the context of local policies which are required to deliver
outcomes for national and international stakeholders when the demands of community
participation may be given low priority. Initiatives to engage the recipients of policy in
planning and implementation may also be compromised when expectations are too high
and, in particular, when too much reliance is placed on the ability of local planning
structures to alleviate intractable social problems which require macro solutions. The
appropriateness of deliberative approaches to community engagement, placing an
unrealistic emphasis on the pursuit of consensus, is also questioned in the literature.
Whilst these findings are derived largely from research on the UK experience of
community participation in decision-making, many are echoed in the policy appraisals
undertaken for the SEKN around the world.
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The SEKN civil society reference group has provided case studies which illustrate the
diverse roles of NGOs in relation to exclusionary processes (SEKN Background Paper
7). These case studies describe work by Street Kids International in Canada, and
AfriAfya in Kenya to develop HIV/AIDS tools relevant to the needs of young people in
Kenya, and activities by the network of Indigenous Researchers, Indigenous
Organisations and Indigenous Community people in Canada aiming to reverse the
marginalisation of indigenous knowledge systems in health services. Two case studies
describe how the Association for Health and Environmental Development and the
Association for Human Rights Legal Aid in Cairo are working to protect the rights of
Sudanese refugees. The role of civil society organisations in highlighting problems is
also illustrated by the work by Central Australian Aboriginal Congress on the social
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The SEKN work in Brazil also highlighted the role of NGOs working to help favela
communities to rid themselves of the drug dealers, militia and corrupt police and to
reduce violence. AfroReggae, the NGO created in 1992, after the slaughter of Vigário
Geral has done some of the most successful work in the favelas, establishing itself over
a 15-year period in four other favelas of the city, with more than 75 projects, one of them
involving military police in workshops with young people. The Favelas Observatory, part
of the Center of Studies and Solidarity Actions of Maré, has been established to develop
new policies to improve conditions in the favelas including most recently policies
designed to provide young people with a route out of crime. More initiatives aiming to
reverse exclusionary processes operating within the Rio favelas are described in SEKN
Background Paper 16. In the next section summaries are provided of some of the other
detailed appraisals of NGO action undertaken by the SEKN.
The work of the Grameen Bank, BRAC and thousands of smaller organisations provide a
powerful illustration of the role of NGOs as providers of microfinance services 21. These
initiatives are targeted at people with no material collateral. As with the state-provided
cash transfers discussed earlier, the cash available in these schemes is conditional on
attendance at weekly meetings involving education and discussion about health issues
and human rights, skills-building and social networking. The scheme uses social rather
than physical collateral: encouraging women to develop broader social networks and
offers a platform for ‘piggy-back’ interventions through the weekly members’ meetings. In
21
This section is drawn from: Schurmann A. 2007. Microcredit, Inclusion and Exclusion in Bangladesh. Background paper
for Social Exclusion Knowledge Network. ICDDR,B Working Paper. ICDDR,B: Dhaka, Bangladesh.
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2004 there were more than 20 million active clients nationwide and research suggests
that microfinance participation is associated with reduced vulnerability to financial
shocks, increased knowledge about and use of qualified healthcare providers, increases
in health knowledge, higher contraceptive use, improved nutritional status especially
amongst girls, and a reduction in desired family size. However, research here and
elsewhere also suggests that credit can increase the vulnerability of poor people with no
entrepreneurial skills, trapping them into debt, and evidence of the acceptability and
compliance with conditions has not been identified. Additionally, most microcredit
enterprises work at too small a scale to achieve efficiency of scale and yield meagre
earnings, so they are limited in their transformational capability.
22
This section is drawn from: Ahmed SM. 2007. Capability Development Among the Ultrapoor: BRAC’s Challenging the
Fontiers of Poverty Reduction/Targetting the Ultrapoor Programme in Bangladesh. Background paper for Social Exclusion
Knowledge Network. ICDDR,B Working Paper. ICDDR,B: Dhaka, Bangladesh.
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reduce disease. BRAC and other civil society organisations are also involved in
providing beds in hostels for low-income women working in the garment industry
(Rashid, 2007).
23
This section drawn from Werner W. 2007. Microinsurance in South Asia: Risk Protection for the Poor? Background
paper for Social Exclusion Knowledge Network. ICDDR,B Working Paper. ICDDR,B: Dhaka, Bangladesh.
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population receiving 26% of government financial subsidies for health and the poorest
quintile receiving16%. The MHI scheme in Bangladesh offers basic healthcare at a
subsidised rate to the poor and ultra-poor and is a joint initiative of BRAC and two
smaller NGOs - Grameen Kalyan and Proshika - in partnership with the private sector
insurance company Delta Life. The aim is to (i) reduce households entering poverty as a
result of a health crisis, and (ii) increase access to and utilization of healthcare. The
insurers stipulate which health facilities are to be used and this has led to the insured
seeking care from trained licensed providers as opposed to untrained providers or self-
treatment. The MHI scheme has increased access to and use of basic health services.
However, because of the extreme poverty of the people targeted, the premiums have
had to be kept low and the scheme is only able to cover basic healthcare. It will not,
therefore, succeed in reducing the likelihood of essential emergency health costs being
a catastrophic expense for low-income households, unlike similar schemes in India,
which have proved better able to spread the risk of catastrophic expenses.
ISODEC formed a coalition with other partners to resist the privatisation of water: After
considerable lobbying the government eventually revised the original conditions from
overall privatisation to a management contract, and although not a great improvement,
the coalition succeeded in obtaining some concessions. Similarly, ISODEC campaigned
against the government’s plan to sell Ghana Commercial Bank shares to a private
investor such as Barclays who would be more likely to close branches outside the main
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cities, thus excluding many poor people from banking facilities. As a result of pressure
the government made the shares available to ordinary Ghanaian citizens who wanted to
buy them.
Participants in the UNDP round-table referred to earlier highlighted many high profile
actions by international NGOs and networks of national organisations which had or were
having significant impacts on exclusionary processes. These include the debt relief
campaign (Jubilee 2000, Christian Aid, GCAP, etc.,), security and post-conflict
reconciliation (Oxfam, Save the Children) and citizen participation in poverty reduction
strategy projects (CIDSE, EURODAD, AFRODAD, World Development Movement and
Christian Aid). Many of these initiatives involve larger, relatively resource-rich NGOs
working in partnership with smaller national and local NGOs, including for example work
monitoring the impact of water privatization (Public Citizen, Commonwealth Foundation,
Christian Aid) and work analysing and enabling civil society action through the
development of a civil society index (CIVICUS with local country partners).
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• Support for social protection systems and public services in formulating the annual
broad economic policy guidelines.
• Revision of the Amsterdam Treaty (Article 137) to: a) provide mechanisms for the
effective guarantee of legal rights to all citizens and residents of the EU, b) make
combating poverty and social exclusion an objective of the Union, c) submit the
adoption of annual broad economic policy guidelines to the democratic process, and
d) provide a legal base for civil dialogue between NGOs and the Institutions of the
EU.
There are also enduring debates about the ‘representativeness’ of NGOs, particularly the
larger ones. Given the diversity in the scale of operation of non-governmental
organisations and community groups (global, regional, national, local) and the activities
they are involved in, their relationship with the constituencies they may claim to serve will
always be problematic. However, it is important to recognise that challenges to the
‘representativeness’ of NGOs are sometimes used in an attempt to discredit
organisations posing legitimate challenges to unfair practices and traditional power
bases. It is unrealistic to expect all NGOs to be fully representative and participative. It
is, however, reasonable to expect them and their funders to be vigilant about
‘representation’. The aim of non-governmental organisations focusing on exclusionary
processes should be to operate in ways which promote inclusion and participation in all
aspects of their internal organisational structures and processes and their externally
directed actions. The ultimate aim must be to support people most severely affected by
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exclusionary processes to act in their own interest, but realistically this is likely to be a
long-term objective.
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monitoring, mobilizing and providing channels for negotiation and a voice within a
multifaceted/ethnic society, training in good governance etc., acting as pressure
groups to change repressive/discriminating policies, legislations and programmes;
and delivering services to support economic and human development.
All NGOs need to attend to issues of representativeness, transparency and good
governance, but it is unrealistic to expect them all to be fully representative of the
groups they seek to represent.
Larger, relatively resource-rich NGOS have an important role advocating for
progressive change at a global level and supporting smaller national and local NGOs
building capacity and working in partnership rather than duplicating efforts or
competing for resources.
The state’s response to social movements in general and civil society organisations
in particular can vary from active support to peaceful co-existence and from neglect
to control and oppression.
National governments need to:
o Recognise the political legitimacy of civil society and ‘community voice’.
o Involve civil society in all its forms in policy development, implementation and
monitoring.
o Enact and implement legal protection for civil society organisations
o Design policies which transfer real power to people who are targeted.
o Resource policy implementation to support ‘community’ empowerment.
o Reform professional education to give greater status to lay/indigenous
knowledge.
• Multi-lateral agencies and other donors can
o Act as role models and promote good practice in relationships with civil
society.
o Provide incentives for governments to work effectively with communities
and NGOs.
o Resource capacity building for civil society and community involvement.
o Promote legal protections for civil society action within nation States.
o Simplify requirements for funding so that smaller community-based
organizations and voluntary groups can access funds and hence develop
capacities.
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However, as the Bangladesh garment industry case study (below) illustrates, even the
most exploitative labour conditions can have unintended positive benefits, greatly in
excess of the action of national governments. Private sector organisations (including
shareholders) can also, in theory at least, make a more formal contribution to policies
and/or actions to reverse exclusionary processes and promote greater social cohesion.
Earlier chapters considered the role of the private sector working in partnership with
other actors, notably the state, to deliver services such as healthcare and health
insurance, including the significant problems which such involvement may entail. This
chapter is concerned with the potential for the private sector to contribute to a reversal of
exclusionary processes through the way they operate their plants, including employment
standards and through the development of greater corporate social responsibility.
Corporate social responsibility can be defined in broad terms as a situation in which a
commercial company goes beyond what is mandatory for them and consciously works to
produce additional benefits for communities they are linked to. A recent report from the
24
Towards Health-Equitable Globalisation: Rights, Regulation and Redistribution. Final report to the Commission on the
Social Determinants of Health from the Globalisation Knowledge Network. Labonte, R and Schrecker, T. 2007.
Final Report from the Employment Conditions Knowledge Network (EMCONET). 20th September, 2007.
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Centre for Global Development (Warden, 2007) identifies six approaches for commercial
organisations to consider if they wish to develop a role in the fight against global poverty
- approaches which are equally relevant to action to reverse exclusionary processes:
• Standards compliance: adhering to high standards for workers’ rights,
environmental protection and other operational issues.
• Charitable giving: through a company foundation or by supporting public or not-
for-profit charitable organisations.
• Commercial leverage: companies doing well by doing good.
• Development entrepreneurship: where an explicit commitment to the poor is the
core business strategy.;
• Policy advocacy: using the company’s influence to improve the policy
environment in a host or home country, supporting the extension of human rights
through legislation and improved governance systems.
Examples of wider social responsibility initiatives are the provision of resources in cash
and/or kind to improve local schools, and introducing educational initiatives to promote
hand-washing and distributing free soap in communities with high rates of diarrhoeal
disease. Corporations typically benefit from their CSR activities through contributing to a
more highly skilled local workforce and better informed consumers, opening up new
markets for their products (e.g. for soap); and by improving their public reputation.
The potential for compliance with high operating and employment standards and greater
corporate social responsibility to reverse exclusionary processes is the focus of this short
chapter. It is important to stress, however, that the SEKN work on corporate social
responsibility has been very limited and few examples of relevant actions have been
formally appraised by the network. The chapter is divided into three sections: the first
provides a case study of the Bangladesh garment industry to illustrate how private sector
action can have unintended positive impacts in reversing exclusionary processes; the
second section is concerned with the potential for standard compliance to enhance
these impacts; the third section provides examples of corporate social responsibility
action on a wider front.
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Garment manufacturers sought women employees because they provided low cost
labour, were perceived to be docile and have low occupational mobility. Previously there
had been little attention to women’s rights, with minimal avenues for women to exercise
leadership. Bangladeshi women have few opportunities to access the formal labour
market and there is highly discriminatory investment in girls’ education and health
compared to boys’. Purdah and early marriage and childbirth restrict women’s mobility
and women have a subservient role in society. However, the garment industry has
begun to change women’s position. Approximately 80% of employees in the garment
industry are women – in stark contrast to women’s employment in non-export industries,
estimated at 7%. This puts the impact of this sector on women’s participation in the
formal economy into dramatic relief.
25
This section is drawn from Khosla N. 2007. The Readymade Garment Industry in Bangladesh: A Pathway to Social
Cohesion? Background paper for Social Exclusion Knowledge Network. ICDDR,B Working Paper. ICDDR,B: Dhaka,
Bangladesh.
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Wages in the garment industry are low, however; there is high stress and working
conditions are poor and hazardous. Research conducted in 2006 in six Dhaka factories
by the international civil society organisation War on Want reported women regularly
working 80 hours a week for £0.05 an hour. The factories included in the research were
supplying the UK stores Primark, Tesco and Asda, which have all made a commitment
to pay a minimum wage of UK£22 a month – calculated as a living wage in Bangladesh.
However, War on Want claimed that wages started at UK£8 per month. In 2006 workers
in the industry went on strike led by the National Garment Workers Federation and won
a 50% rise in the minimum wage to UK£12 a month – still well below a living wage.
There have also been a number of major fires and building collapses in the last few
years which killed or injured hundreds of people.
The case study of the Bangladesh garment industry powerfully illustrates the potential
benefits which can accrue when major companies locate in low-income countries and
also points to the potentially profound social changes this can trigger even when
conditions fall far short of good labour practice. It points to how much greater this
contribution could be if operating and employment standards were high and private
sector companies took their ‘corporate social responsibility’ more seriously.
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warning that no country – no matter how rich – is free of seriously hazardous working
conditions. Following this disaster, under the provisions of the Gangmasters (Licensing)
Act 2004, a Gangmasters Licensing Authority has been set up to curb the exploitation of
workers in agricultural, horticultural, shellfish-gathering and associated processing and
packaging industries. But many workers, particularly foreign workers including those
legally entitled to work in the UK, still experience very poor working conditions,
inadequate living conditions, and hostility from more established population groups with
whom they are perceived to compete 26.
Most multi-lateral initiatives, such as the Ethical Trading Initiative (ETI) are voluntary.
The ETI is an alliance of 29 companies, trade unions and NGOs aiming to promote
compliance amongst more than 20,000 supplier companies worldwide with a Code of
Labour Practice focusing on discrimination, health and safety, working hours, wage
levels and provision of social protection including pensions and child labour. Voluntary
initiatives can have positive impacts. An independent evaluation of the impact of the ETI
Code of Labour Practice (Barrientos & Smith, 2006) for example, reported improvements
in health and safety standards, reduced working hours, compliance with minimum wage
regulations, enhanced social protection - including pension provision and a reduction in
26
SEKN Background paper 8
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child labour - with the greatest impact being on health and safety standards. This
evaluation focused on countries as diverse as the UK and China.
However, given the scale of the problems generated by poor working conditions globally,
it seems clear that voluntary initiatives will inevitably be limited in their impact. The
authors of the report on the evaluation of the ETI Code of Labour Practice referred to
earlier, for example, note that ‘serious issues frequently remained’ in relation to freedom
of association and discriminatory employment practices and that the improvements they
identified were not being felt by the most marginalised temporary or causal labour – a
picture likely to be repeated around the globe. Attempts to improve working conditions
and encourage voluntary compliance with labour codes are also undermined by
developments such as the ‘Export Processing Zones’. EPZs involve exemptions from
part or all of labour codes as well as other fiscal and financial incentives to attract foreign
investors. The International Confederation of Free Trade Unions (ICFTU) reports
“serious shortcomings in the application and enforcement of all eight core labour
standards, particularly with regards to the lack of trade union rights of workers including
the right to strike, discrimination and child labour.”
The 2007 UNDP Report includes impressive examples of partnerships with commercial
companies established under the umbrella of the UN Global Compact aiming to reverse
exclusionary processes. Growing Sustainable Business, for example, has supported ten
projects in Kenya that are expected to generate over US$70 million in additional
revenues and impact directly on 42,000 beneficiaries. A UNDP partnership with the ANZ
Bank in Fiji is reported to have led to 60,000 new bank accounts being opened in rural
areas, significantly increasing access to credit, and this has now been extended to the
Solomon Islands and Tonga.
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Given the primacy of the profit motive in the private sector, there will inevitably be limits
to the potential for voluntary initiatives established in the name of corporate social
responsibility to address social exclusion. In recognition of these limits, the large
international NGO War on Want (WoW) is orchestrating a global campaign for greater
corporate social responsibility. As part of this campaign WoW is targeting shareholders
in an attempt to gain support for resolutions to be passed at Annual General Meetings.
These would require companies to appoint independent auditors to inspect the premises
of companies working on contract to supply goods to large multi-nationals to ensure that
workers in supplier factories and farms are guaranteed decent working conditions, a
living wage, job security and the right to join a trade union of their choice. War on
Want’s campaign is part of a much broader social movement involving a range of civil
society actors focusing on corporate accountability (Christian Aid, War on Want, World
Development Movement) and fair trade and market access for poor countries more
generally (Trade Justice Movement coalition, Third World Network, Christian Aid, Oxfam,
International Gender and Trade Network).
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• The SEKN has given relatively little attention to the specific contribution the private
sector can make to reversing exclusionary processes. Other knowledge networks,
particularly those focusing on globalisation and employment conditions, have dealt
with relevant issues in much greater detail.
• The role of the ‘for profit’ sector in providing essential services such as healthcare
and health insurance were discussed in Chapter 5. This work has identified a role
for the private sector working with other partners, notably multi-lateral agencies,
national governments and civil society organisations to increase service capacity and
extend access to basic services. However, the work has also highlighted serious
contradictions and constraints on these approaches including
o Public resources being directed to profits which could be used to extend
access to and/or improve the quality of services.
o Gross inequalities in quality of services in parallel public and private sectors
of healthcare, and resources and professional personnel being ‘captured’ by
the private sector.
o A bias towards urban areas and acute care in private sector provision
neglecting preventive care and popular health promotion.
o Perverse incentives for private providers to increase throughput rather than
focus on outcome, which can increase exclusionary processes.
o The limitations of insurance-based approaches in protecting against risks in
populations experiencing severe poverty.
• Beyond service provision private sector organisations may contribute to reversing
exclusionary processes in two broad ways: complying with high standards in
operation and employment in their own companies and the companies which supply
them; and action to extend corporate social responsibility on a wider front.
• Private sector companies may contribute to social transformation by employing
disadvantaged groups even when labour conditions fall far short of good practice, but
this is not an alternative to improving employment conditions.
• Legislation protecting the terms and conditions of paid labour is reasonably well
developed in high income countries, but it has been under attack in recent years and
even in the most regulated economies there are segments of the labour force where
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conditions are very poor. Legislative protection of workers is urgently required in all
areas of the world and particularly in the context of globalisation.
• There is some evidence that voluntary initiatives to promote compliance with higher
operating and employment standards and support greater corporate social
responsibility can lead to improved labour conditions and have wider impacts on
exclusionary processes, but the reach and impact of these initiatives are insignificant
set against the powerful exclusionary processes driven by current global trade
relationships.
• Community action and action by non-governmental organisations has significant
potential to increase pressure for greater corporate social responsibility in the private
sector including demanding greater formal regulation of labour conditions and
environmental protection and more rigorous monitoring of compliance.
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This part of the report consists of two chapters. In Chapter 9 the key messages from the
work of the SEKN are summarised. Chapter 10 presents the main recommendations
from the SEKN to the WHO Commission on the Social Determinants of Health.
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Globally, there are few policies or actions specifically labelled as addressing social
exclusion. The SEKN has therefore had to rely on a combination of theory and
pragmatism to select policies and actions to be appraised. Additionally and importantly,
selection of a particular policy/action is not intended to signal an endorsement by the
SEKN or to suggest that the policies and/or actions included represent examples of good
practice in addressing social exclusion. On the contrary, our aim has been to appraise a
diversity of policies/actions in order to form a judgement about the relative merit of
different approaches. Policies and actions included in this report were selected to
provide diversity in terms of global reach, the actors involved and the focus of the
actions. We have not undertaken a comprehensive review of all potentially relevant
policies and action, nor did we not seek to include only policies/actions that could be
labelled a priori as good practice: judgement was dependent on the appraisal. The
‘actors’ involved included national and local governments, multi-lateral agencies,
community groups and non-governmental organisations and private sector
organisations. The policies and actions included approaches to poverty
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The SEKN believes it is important to distinguish between the use of the phrase ‘social
exclusion’ to describe a state experienced by particular groups of people as opposed to
a relational approach to understanding social exclusion in which it is used to describe
multi-dimensional processes which lead to differential inclusion and exclusion in social
systems. In a policy context, social exclusion is most commonly used to describe a
‘state’ in which people or groups are assumed to be ‘excluded’ from social systems and
relationships. In most definitions this state is seen to be associated with extreme poverty
and disadvantage. As one author notes, the term is now so widespread that it has
become ‘a cliché used to cover almost any kind of social ill’ (Bessis, 1995). Many
definitions include long lists describing groups excluded or at risk of exclusion, what they
are excluded from, the resultant problems, and the ‘actors’ responsible for excluding
groups. Beginning in France in the 1970s, a discourse of social exclusion (and
inclusion) as a ‘state’, and policies and actions informed by this concept, have spread
from the Northern Hemisphere to the South, mainly through the efforts of United Nations
agencies such as the International Labour Organisation (ILO) and the work of individual
nation states such as the aid programmes of the Department for International
Development (DFID) in the United Kingdom.
The SEKN has adopted a relational approach to understanding social exclusion. From
this perspective exclusion is viewed as a dynamic, multi-dimensional process driven by
unequal power relationships. In the SEKN conceptual model exclusionary processes
operate along and interact across four main dimensions - economic, political, social and
cultural - and at different levels including individual, household, group, community,
country and global regional levels. These exclusionary processes are assumed to
create a continuum of inclusion/exclusion characterised by an unjust distribution of
resources and unequal access to the capabilities and rights required to:
27
Available on the WHO CSDH website or contact j.cox@ Lancaster.ac.uk for more information
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In an attempt to move beyond the limitations of formal quantitative indicators the SEKN
has used case-studies to provide a window on the nature and scale of exclusionary
processes and their impacts. These thematic case-studies focus on economic
inequalities and poverty, displacement, HIV and AIDS, and cultural discrimination. The
SEKN believes that the complexity of the concept of social exclusion - its multi-faceted
nature including both objective and subjective elements – cannot be fully and sufficiently
captured in numbers and indicators and hence formal indicators cannot be an adequate
foundation for policy and action. Rather, the nature and impact of exclusionary
processes can only be adequately ‘represented’ through both quantitative and qualitative
data – through both indicators and stories. This is the only way to maximise effective
policy and action to address exclusionary processes.
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Universal welfare systems played a key role in the economic and social development of
OECD countries by reducing poverty, reversing exclusionary processes, promoting
social cohesion and improving population health. Despite pressure to reduce spending,
recent research shows that OECD countries have continued to increase spending on
social protection and essential services. Today these countries spend on average one
eighth of their GDP (12.6%) on public social security cash benefits and more than a fifth
(20.9%) on public social services and social security together (excluding education).
Evidence that reducing spending promotes higher economic growth is inconclusive
whilst substantial spending of more than a sixth of GDP is often consistent with above-
average economic growth (Townsend 2007). Reviewing the evidence on the OECD
experience, Peter Townsend argues that ‘the strength of a universalistic, human rights
approach to social security is in turning to future advantage what, after extraordinary
struggle, proved to be a highly successful strategy in the past’ (Townsend, 2007:.vii).
The prize to be achieved is in reducing financial hardship whilst also promoting social
cohesion, political inclusion and cultural diversity.
Over the past decade the advantages of comprehensive systems of social protection
and universal public provision of services such as healthcare, education, water,
sanitation, etc., funded through taxation and social insurance, have again been
recognised partly through the campaigning work of international agencies including ILO
and UNDP and major civil society organisations such as Oxfam, and a growing body of
evidence suggesting that these approaches are the most effective, efficient and
sustainable way of reversing exclusionary processes along the four dimensions identified
in the SEKN model: social, economic, cultural and political (Oxfam, 2006; Mkandawire
2005; ILO, 2005; 2006; Chung & Muntaner, 2006; UNDP 2007; Townsend, 2007).
Comprehensive publically funded social security and services for three groups in
particular – children, the disabled and the elderly – are central to these approaches.
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The historical investment in OECD countries is far in excess of the proportion of national
income devoted to social services and social security in low- and middle-income
countries today. However, some countries are pursuing universal approaches to social
protection and the provision of health, education and other essential services, even
though they may be introduced in stages. These universalist policies in, for example,
Brazil, Venezuela and South Africa, are associated with major improvements in access
and use of services, reductions in poverty levels and there is evidence of positive health
and educational outcomes and greater social cohesion and solidarity. Public provision of
social protection and essential services also has the potential to generate multiplier
effects in local economies particularly those consciously designed into programmes
through, for example, mandating the use of local enterprise to provide services.
Mirta Roses Periago, Director of the Pan American Health Organization, notes in her
foreword to the appraisal of the Venezuelan ‘Barrio Adentro’ that it provides an
alternative model to that which is currently dominating social protection policy globally.
Whilst many governments are seeking to improve health through self management,
personal responsibility and the transfer of responsibility for care from the state to civil
society with reduced public expenditure, Venezuela is one of a number of countries
experimenting with a model of co-responsibility between the State and its citizens with
the state acting as guarantor of social rights. Funding these services is clearly an
important challenge. In Venezuela oil reserves have obviously made the Barrio social
missions experiment easier to implement. By 2005 around US$5 billion from this source
had been invested in social missions to supplement mainstream budgets for government
departments. This has implications for the transferability of such policies, but countries
like South Africa and Brazil have also implemented universal policies without the benefit
of additional ‘windfall’ resources. There is a need for multi-lateral agencies and donors
to rise to this challenge and develop ways for universal systems of social protection and
essential services free at point of use to be funded in low- and middle-income countries,
including global tax systems. The ILO is currently undertaking work on this linked to
their global campaign on Social Security and Coverage for All.
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and involving some kind of means-test. Targeted means-tested cash transfers can lead
to improved household incomes in the short term, with evidence that in the longer term
they can increase household assets and create positive incentives for people to seek
work to continue to raise their living standards. These policies can also trigger wider
multiplier effects in local economies by investing resources in local service providers (as
would be the case with universal provision as well). Evidence from evaluations of the
South African Child Support Grant and the Child Benefit in the UK suggests that mothers
will spend cash benefits on promoting the health and wellbeing of their children through,
for example, the provision of more nutritious food, clothing, payment of school fees and
purchase of school equipment. Targeted means-tested policies providing access to
essential services such as healthcare and education are also resulting in significantly
increased coverage.
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• There is great potential for fraud in complex systems for proving eligibility and
monitoring compliance, poor quality governance systems, low paid staff and
inadequate training.
• The complexity of eligibility processes and fraudulent systems encourage leakages
of resources to people who are not eligible.
• Delayed or incorrect payments to recipients and/or service providers frequently arise
because of complex systems combined with weak administrative processes.
• Perverse incentives can be created by eligibility rules (e.g. claims that young women
are getting pregnant to obtain the CSG in South Africa) or provider payment systems
(e.g. a per capita subsidised insurance system in Colombia with no attention to
outcomes may be leading to problematic rationing of services).
• Inadequate state funding can undermine the effectiveness of policies.
• Targeted policies may reduce absolute poverty and disadvantage but leave
inequalities between the poorest and the rest of society unchanged or, in the worst
situations, widening.
Globally, there has been a rapid move to attach conditions to the receipt of targeted
transfers of cash or services. These conditional transfer policies raise important
evidential questions and issues of principles and values. A growing body of research
suggests that conditional transfer programmes can have significant positive impacts
including poverty reduction, improved living standards and improved health and
educational outcomes. However, potential benefits notwithstanding, not only do these
policies have all the limitations of unconditional targeted action they are also open to
other equally important criticisms. Some programmes, for example, fail to provide the
services people require to meet the conditions, and/or pay little attention if any to the
often poor quality of services. When conditionality refers to labour market participation,
the quality and sustainability of employment is often neglected or ignored. Furthermore,
evidence on the ‘value added’ nature of ‘conditionality’ per se is inconclusive; whilst
other evidence suggests if conditions ‘fit’ with household priorities – to protect child
health for example - ‘conditionality’ is not needed. The widespread and indiscriminate
use of programmes designed around conditionality and aimed at the most
disadvantaged individuals and households is particularly problematic given, as
Townsend (2007:ix) notes, a large body of evidence accumulated over many years that
‘the more conditional and even punitive forms of transfers are counter-productive for
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other targeted policies/actions: complex and restrictive eligibility procedures, high risk of
fraud and corruption and limited capacity to meet demand. Another model of social
insurance, more common in Asia, is schemes run by NGOs which protect people against
catastrophic health events and/or environmental hazards such as floods and drought.
Whilst large examples of these schemes in India have been reported to be very
successful, the example included in the SEKN appraisals in Bangladesh illustrates the
limits of such schemes in very poor communities where the resource base is insufficient
to fund adequate cover.
Multi-lateral agencies and pan-regional bodies are also seeking to promote and support
better co-ordination and cross-national learning about policies/actions with potential to
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A number of generic lessons can be learned from international and national initiatives
aiming to support better co-ordination and integration of policies and actions with
potential to reverse exclusionary processes. In general these initiatives will work more
effectively if the following conditions are in place:
• Systems for measuring and monitoring which combine objective indicators with
experiential/subjective understandings and aim to capture the dynamics of
exclusionary processes, not just describe changes in states of exclusion.
• An explicit recognition that action to address exclusionary processes in general, and
poverty in particular, are political and therefore require formal mechanisms to
manage these political processes. International agencies can be effective arbitrators
at national level in some contexts. The aim should be to establish social exclusion
and poverty as bi-partisan issues.
• Strong and senior political commitment and leadership.
• Institutions established to take the initiative forward independent of the state, with
credibility as knowledge brokers/translators, the power to make decisions and
holding others accountable for acting individually and/or in partnership to deliver
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It is now widely accepted that people who are the targets of policies and actions aiming
to reverse exclusionary processes have a right to be actively involved in the design,
delivery and evaluation of these policies and actions. Their involvement will ensure that
the full range of relevant knowledge – lay and professional, scientific and experiential –
informs policy and action and hence increases the likelihood of these policies and
actions being appropriate, acceptable and effective. In many countries, particularly but
not exclusively those with strong scientific communities, the uncodified knowledge of lay
people, particularly indigenous people’s, are routinely devalued and the potential is lost
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for this knowledge to shape more appropriate, acceptable and potentially more effective
responses.
Community involvement can be the key to successful policy and/or action to reverse
exclusionary processes but it cannot solve large-scale structural problems. Genuine
engagement with lay communities must also involve a transfer of real power, and
resources must be dedicated to support lay people to become involved in policy and/or
action. Without support, community activists can be damaged by their experiences –
blamed by their communities for failing to deliver real change and held accountable by
professionals for the communities they represent. Community involvement in action to
reverse exclusionary processes can only be effective when embedded in effective state
action to provide decent living standards and essential services. It is also important to
recognise that professional workers will often resist the challenge to their power-base,
which is inherent in effective community involvement. The agencies involved should
therefore ensure that appropriate training and technical support is available – for both
professionals and community activities – to support the cultural change which is required
and to increase knowledge and skills.
The state’s response to social movements in general and civil society organisations in
particular can vary from active support to peaceful co-existence, and from neglect to
control and oppression. National governments need to:
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There is some evidence that voluntary initiatives to promote compliance standards and
to encourage greater social responsibility in the private section can lead to improved
labour conditions and may have wider impacts on exclusionary processes, but the reach
and impact of these initiatives are insignificant set against the powerful exclusionary
processes driven by current global trade relationships. Wider social movements
including action by large international NGOs are increasing the pressure on the private
sector to comply with higher labour standards and demonstrate greater social
responsibly in terms, for example, of investing in low communities and protecting the
environment. However, as the reports of the Globalisation and Employment Conditions
Knowledge Networks powerfully demonstrate, these initiatives are having only a
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marginal impact on the scale of exclusionary processes currently driving social and
health inequalities around the globe.
This chapter has provided an overview of the key messages arising from the work of the
WHO Social Exclusion Knowledge Network. These messages relate to the diverse
meanings attaching to the concept of social exclusion; the distinction between social
exclusion understood as an extreme state of disadvantage or as multi-dimensional
processes generating profound inequalities in societies including health inequalities; the
challenges of measuring the concept however it is defined and the benefits and
limitations of current policies and actions focusing either directly or indirectly on
reversing exclusionary processes. The recommendations for action flowing from this
work are many and varied focusing on questions of values and principles to questions of
data and interpretation, from matters of detail to high level strategic action by
international agencies and global corporations. In the next chapter we turn to consider
some of these implications for action focusing primarily on high level questions rather
than matters of detailed policy formulation. These implications for action are framed
here as recommendations to be considered by the WHO Commission on the Social
Determinants of Health as they decide on the content of their final report but it is hoped
that they will be seen to have wider relevance for all those agencies with a role to play in
reversing exclusionary processes and promoting greater social cohesion at all levels in
our global society.
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As noted at the end of the previous chapter, the work of the SEKN reported here raises
important principles concerning the value placed on social justice, equity and social
cohesion in the formulation of policy and action, and empirical questions about how
social exclusion is best understood and measured from a policy and/or or action
perspective - particularly from the perspective of social determinants of health. The
policies and actions appraised are diverse, and few of them are explicitly labelled as
focusing on social exclusion. Very few have been subject to a robust evaluation, so the
SEKN appraisals have, of necessity, had to be pragmatic, making use of whatever data
on process and/or impact was available. At one level all seek to reduce or eradicate
poverty and/or its many adverse consequences, including extending access to essential
services, particularly healthcare and education. But underlying this commonality are
profound differences in the ultimate aim of these policies and actions, some seeking to
establish publically funded universal provision to reduce inequalities across societies,
whilst others have the narrower aim of improving the conditions of the poor.
These reasons make it inappropriate for the network to make detailed recommendations
on specific discrete policies or actions. Rather, the strength of the SEKN work is in
highlighting higher-level lessons for future policy and action, aiming to reverse
exclusionary processes. These are considered below under the following thematic
headings:
• The policy/action advantages of the concept of social exclusion
• The primacy of universal rights and full and equal inclusion
• The responsibility of the state
• Social movements and community empowerment
• The role of multilateral agencies and donor agencies
• The limits of targeting and conditionality
• The limitations of insurance based approaches
• The need for policy/action co-ordination
• The role of the private sector
• Measurement, monitoring and evaluation
• Future research.
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There is huge diversity in social relationships of power and control within and between
societies and global regions and how exclusionary processes are expressed. Similarly,
there is diversity in the meanings attaching to the concept of social exclusion, its
acceptability as a framework for policy and action across global regions and nation
states, and within popular discourse. This diversity should, however, not be allowed to
mask the commonality of exclusionary processes around the world and their
fundamental expression, in terms of inequalities in human dignity, human rights and
human health. In this context, national governments, international agencies, civil
society and private sector actors should:
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11. Only use the term 'social exclusion' when more precise and informative
descriptors of the phenomena to be targeted, such as food insecurity or
racism, are not available.
12. Focus on the multi-factorial relational processes driving differential inclusion
and conditions of extreme exclusion, rather than solely on ameliorating the
conditions experienced by groups labelled as ‘social excluded’.
13. Attend to all the dimensions of exclusionary processes - social, political,
cultural and economic – and the interactions between them when developing,
implementing and evaluating policy and action.
14. Consider the value of using the SEKN conceptual model as a tool for
developing more comprehensive policy and action to address social
exclusion and as a framework for evaluation.
Recommendation theme 2: The primacy of universal rights and full and equal
inclusion
The primary aims of all policies and action aimed at reversing exclusionary processes
and promoting full and equal inclusion should be to:
• Provide full and equal membership of social systems.
• Provide universal access to living standards which are socially acceptable
to all members of a society, including access to the same level and quality
of health and educational services, safe water, sanitation and ‘decent
work’, as defined by ILO.
• Respect and promote cultural diversity.
• Address unequal inclusion as well as situations of extreme exclusion.
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• Developing conditions which require and support other actors, including public
and private sector organisations and non-governmental organisations, to act to
reverse exclusionary processes and promote full and equal inclusion for all
groups whilst respecting cultural diversity.
• Resisting the actions and influence of international agencies likely to increase
exclusionary processes.
• Promoting and supporting community empowerment.
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The problems with subsidised healthcare insurance schemes have been described in
detail by the CSDH Health Systems Knowledge Network. The same problems are likely
to arise with similar means-tested subsidised insurance schemes aimed at protecting
people living in the most disadvantaged conditions from other risks, such as adverse
environmental events like flooding and crop failure. Although such schemes may offer
protection to some, evidence from the healthcare field suggests that limited coverage,
frequent exclusion of the very poorest, and weak capacity, will severely limit their ability
to reverse exclusionary processes. Like other means-tested provision such schemes are
likely to be stigmatising and hence be associated with low take-up and high transaction
costs. They may only provide protection for minor events, produce a two-tiered system of
care, and can introduce perverse incentives with private sector companies rationing
protection to maximise profits, with the potential to create negative consequences for
health and wellbeing. In this context:
• Insurance-based systems of social protection should only be implemented within
a public policy framework oriented towards a guarantee of human rights and
universal access to essential services and socially acceptable living standards.
• Means-tested subsidised insurance schemes should be avoided which are aimed
at providing protection from risks for people most severely affected by
exclusionary processes.
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at national level in some contexts. The aim should be to establish social exclusion
and poverty as bi-partisan issues.
• Strong and senior political commitment and leadership, and institutional actors with
credibility and stature to act as champions for the policies/actions involved.
• Institutions established to take the initiative forward independent of the state, with
credibility as knowledge-brokers/translators, the power to make decisions, and
holding others accountable for acting individually and/or in partnership to deliver
change. Examples include a Standing National Commission, an Independent Board
or a ‘champion’.
• A process to ensure sustainability of the initiatives in the longer term by integrating
changes into mainstream policy-making processes and service delivery systems.
• Resources and time dedicated to capacity-building – in terms of the technical skills
and competencies required for problem definition, knowledge generation and
knowledge translation, and policy/action implementation and monitoring.
The initiatives appraised also point to the value of ensuring adequate opportunities for
sharing of learning across national and sub-national contexts; although diversity in
policies and actions reflect different political priorities and policy dynamics, it also
provides a rich basis for comparative analysis and learning
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1. DESCRIPTION
A. Provide a description of the country context:
Collating available information on the geographic, social and economic characteristics of
the country in which the policy is based (obviously this will not apply to policies at
international level). An alternative to presenting data in the report is to use available
data to allocate a country to one of the categories developed by Chung & Muntaner
(2006). 28
B. Provide a ‘picture’ of social exclusion (or a specific element of this) in the
location where a policy/action is being developed and/ or delivered.
The location may be international/national or local. The picture of the location and
relevant data collection could be framed by the following questions:
• Is social exclusion (or an element of it) defined explicitly in policy? Or is there a
similar concept?
• What is the impact of social exclusion, on what outcomes, at what level?
• Who is affected?
• Through which institutions and processes?
• What are the main constraints to tackling social exclusion?
• Where are the entry points and opportunities for doing so?
28
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328-339
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• Is there any explicit link being made between the focus on social exclusion and
pathways to health inequalities?
• Who is targeted by it? Who designed and delivered it? What, if anything, was the
particular role of the health system?
• What evidence, if any, was used in the process of policy development and/or
delivery? When was it delivered and over what period? What institutional
arrangements are involved (including who funded it, and if a donor agency,
provide a link to the donor's information about criteria, program objectives)?
• What enforcement mechanisms/incentives, if any, are built into the
policy/action/programme for the deliverers and/or the target group?
• What evidence is there on impact (intended or unintended; positive or negative)
and how robust is the evidence?;
• How much is being spent (which donors? what program?)?
• In what social/economic/cultural context is it being implemented?
• Is the policy/action/programme being monitored and/or formally evaluated?
• What methods are being used and who is involved?
• What action, if any, is being taken to sustain the policy/action/programme into the
future?
2. EXPLANATION:
The focus here is on identifying factors which may help to explain why the policy/action
came about and why it had the impact (intended or unintended; positive or negative) it
had. Key questions structuring the data collection would include:
• How did the policy/action/programme originate?
• What type of ‘case’ was made for the policy/action/programme e.g.
economic/cost effectiveness, equity and social justice, etc?
• Do these policies/actions have any historical significance – has social exclusion
been a political issue in the past?
• Were there any particular contextual factors in the policy delivery location which
shaped implementation and/or impact positively or negatively?
• What influence did the prevailing political local/national/international climate have
on the emergence/development and/or delivery of the policy/action/programme?
• How did the target group react to the policy?
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3. TRANSFERABILITY: GENERALISABILITY
Finally the analyst should attempt to assess the feasibility of generalizing from the
policy/action/programme appraisal and/or case study to other situations/conditions.
There are two broad and not mutually exclusive approaches to exploring the potential for
generalizing for a single policy/action case involving the development of theoretical
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and/or empirical arguments: making a theoretical case and/or making an empirical case.
The exploration of generalisability will be aided by cross-case comparisons.
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KN Knowledge network
LEAPS Livelihood Empowerment Against Poverty Scheme (Ghana)
LEDCs Less economically developed countries
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SA South Africa
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